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CAUSES OF DISABILITY 



AS APPLIED UNDER 



ACCIDENT AND HEALTH INSURANCE 
POLICIES 



CAUSES OF DISABILITY 



AS APPLIED UNDER 

ACCIDENT AND HEALTH INSURANCE 

POLICIES 

WITH SPECIAL CHAPTERS ON 

POLICY FORMS, ADVANTAGES OF EXAMINING FOR ACCIDENT INSURANCE 
COMPANIES. NECESSARY QUALIFICATIONS FOR SUCCESSFUL EX- 
AMINERS, METHOD OF MAKING EXAMINATIONS, ADJUSTING 
CLAIMS AND MANNER OF SECURING APPOINTMENTS 
AS EXAMINERS FOR INSURANCE COMPANIES 



Designed for the Use of Insura?ice and Fraternal Examiners , General 

Practitioners and Students of Medicine, 

Attorneys and Corporations 

BY 

CHARLES HAMILTON HARBAUGH, M. D. 

Expert Examiner and Adjuster, Medical Director American Assurance Company, 

Ex-President American Association of Medical Examiners and 

Philadelphia Medical Examiners' Association, 

Formerly Demonstrator of Syndesmology in the Jefferson Medical College 

of Philadelphia, 

Member of the American Medical Association, Philadelphia County Medical Society, Etc. 



ILLUSTRATED WITH ONE HUNDRED AND TWENTY-THREE HALF TONES AND 
FIFTEEN FULL PAGE PLATES, ELEVEN IN COLORS 



THE SPECTATOR COMPANY 

Selling Agents 

NEW YORK 



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LIBRARY of CONGRESS 
Two Copies Received 

MAR 13 1909 

Copyrltrnt Entry 

XJLASS <^ XXc, No. 

COPY 8. 



Copyright. 1909 
By Charles Hamilton Harbaugh, M. D. 



TO MY 

DEAR FATHER AND MOTHER 

THIS VOLUME IS AFFECTIONATELY 

DEDICATED WITH LOVE AND ESTEEM BY 

THE AUTHOR 



PREFACE 



The casualty insurance business as exemplified by the issuing 
of poHcies providing indemnity against disability resulting from 
accidents and diseases is acknowledged by experts as the form of 
insurance which will in time far surpass all other kinds. Already 
an enormous number of accident and health policies are being 
written annually by many reliable and well managed casualty in- 
surance companies on wage earners who know by precept or 
experience the value of such insurance. 

Practically every man desires to leave his family provided 
for in case of unexpected death, and it is absolutely necessary for 
honorable men to provide for them during life. This can be done 
in a more or less satisfactory manner as long as the head of the 
household is able to work. AVhen accident or illness causes a 
temporary or permanent period of disability, the income usually 
ceases at once unless the individual has protected that income 
with an accident or health policy, and as a large number of men 
are now carrying such policies, an already vast amount of exam- 
ining for casualty insurance companies by physicians and sur- 
geons is being done every day, but nothing in comparison to the 
number of examinations that will be necessary within the next 
few years. For this class of work which is now required and 
which will enormously increase in the coming years, it behooves 
medical men to prepare themselves to render proper services to 
the company they represent, the claimant and themselves, thereby 
improving their social standing and materially increasing their 
income. 

It is a well recognized fact that nothing can be done well 
without instruction and experience, the greater the knowledge 
of any special line of work possessed by a doctor the larger the 
amount of success will he acquire in his chosen vocation. Years 
of experience have shown the great need that exists among doc- 
tors for a book oivino- information concernino- accident and health 
insurance examinations. It hardly seems pix^sible, nevertheless 



viii PREFACE 

it is true, that the majority of American physicians are not famil- 
iar with the demands which are now existing for medical examina- 
tions and reports from casualty insurance companies. As the 
medical profession has never had a book on accident and health 
insurance for instruction and advice, this book was undertaken 
and is now given to those concerned in this great field with the 
hope that whatever is contained therein will prove of interest and 
value. 

The author takes this opportunity of extending sincere 
thanks to many who have contributed suggestions and advice, 
and especially is he indebted to Mr. John Guy Monihan, President 
of the Monihan Company; Mr. R. W. Greene, Vice President of 
the W. B. Saunders Company; Mr. A. H. Lea, of Lea & Febiger, 
and Mr. Milton Campbell, President of the H. K. Mulford Com- 
pany for many courtesies granted during the actual preparation 
of the book. For the splendid index with which this volume is 
equipped special mention is due my secretary, Miss Florence E. 
Tunney, whose services have been invaluable in many ways. 



C. H. H. 



1 143 South Broad Street, 
Philadelphia, Pa. 



CONTENTS 



CHAPTER I 

ADVANTAGES OF MAKING ACCIDENT, HEALTH AND 
LIABILITY INSURANCE EXAMINATIONS 

Page 1 
Demand for Examinations — Time of Examination — Urinary and Microscopic 
Examinations — Anxiety — Accident Insurance Physician's Welcome — Ad- 
ditional Fees in Court Trials — Examination Before Policy is Issued — 
Physician's Time — Increasing Acquaintance — Diagnosis and Prognosis — 
Adjusting — Compensation. 

CHAPTER 11 

NECESSARY QUALIFICATIONS FOR A SUCCESSFUL 
INSURANCE EXAMINER 

Page 9 
Personal Appearance — Age — Graduation — Experience — A Specialty — Tact — ■ 
Method — Accommodating — Promptness — Conciseness — Relations With 
Agent — Inspection — ^Age, Height and Weight — Differential Diagnosis — . 
Cross-examination of Claimant — Impartial Reports — Explanations — Good 
Impression by Examiner — Responsibility — Fees and Bills. 

CHAPTER III 

EXAMINING FOR ACCIDENT INSURANCE COMPANIES 

PART I 

ACCIDENT EXAMINATIONS Page 23 

Purpose of Examination — Place of Examination — Examination Without At- 
tending Physician— Examination With Attending Physician — Examina- 
tion—Company Requirements— Medical Terms— No Prescribing by Ex- 
aminer—No Criticism of Attending Physician— Diagnosis and Prognosis- 
Remarks — Blank. 

PART II 

HEALTH EXAMINATIONS P^?^ ^^ 

Purpose of Examination— Place of Examination— Examination Without At- 
tending Physician— Examination With Attending Physician— Examina- 
tion— No Prescribing— No Criticism of Attending Physician— Blank- 
Diagnosis — Prognosis — Remarks. 

ix 



s CONTENTS 

PART III 

LIABILITY EXAMINATIONS Page 37 

Permission to Make Examination — The Purpose of the Examination — Place of 
Examination — Relations of Examiner — Blank — Explanation of Blank — 
No Prescribing by Examiner — No Criticism of Treatment. 

CHAPTER IV 

POLICY FORMS 
PART I 

ACCIDENT POLICIES Page 47 

Accidental Death— Loss of Two Limbs or Eyes— Loss of One Limb or One 
Eye — Indemnity for Total Disability — Indemnity for Partial Disability — 
Combination Benefits — Elective Indemnities — Fees for Surgical Opera- 
tions — Accumulations— Special Death Indemnity — Change of Occupation 
— Advanced Payments — Notice of an Accident — Identification — Bene- 
ficiary Insurance — Cancellation — Medical Attention — Medical Examina- 
tion — Remarks. 

PART II 

HEALTH POLICIES P^^e 56 

The General Health or Disability Policy— The Special Health Policy— Com- 
bination Policies— Permanent Disability— Total Disability— Partial In- 
demnity for Total Disability— Surgical Indemnities— Quarantine Indem- 
nity. 

CHAPTER V 

INJURIES AND DISEASES OF THE HEAD AND NECK 

CAUSED BY ACCIDENTS AND RESULTING IN 

DISABILITY 

PART I 

SCALP P^^^ ^1 

Abrasions— Contusions— Incisions— Lacerations— Punctui-ed Wounds— Burns 

and Scalds. 

PART H 

FACE P^Se 70 

Abrasions— Contusions— Incisions— Lacerations— Punctured Wounds— Burns 

and Scalds. 

PART III 

EYELIDS P^^^ ^^ 

Abrasions— Contusions— Incisions— Lacerations— Punctured Wounds— Burns 

and Scalds. 

PART IV 
CORNEA AND SCLERA P^S® ^^ 

Ulcers of the Cornea and Sclerotic Coat— Conjunctivitis. 



CONTENTS xi 

PART V 
EARS Page 90 

Injuries of the Auricle — Abscess of the Middle Ear. 

PART VI 
SKULL Page 94 

Fractures of the Skull — Punctured Wounds of the Skull. 

PART VII 

BRAIN Page 100 

Abscess of the Brain — Concussion of the Brain. 

CHAPTER VI 

INJURIES AND DISLOCATIONS INVOLVING THE 
JOINTS AND BONES OF THE FACE 

Page 105 
Dislocation of the Temporo^Maxillary Articulation — Fracture of the Nasal 

Bones — Fracture of the Malar Bones — Fracture of the Superior Maxillary 
— Fracture of the Inferior Maxillary. 

CHAPTER VII 

INJURIES TO THE NECK INCLUDING THE LARYNX 

AND TRACHEA 

PART I 

NECK Page 115 

Abrasions — Contusions — Incisions — Lacerations — Punctured Wounds — Burns 

and Scalds. ^ 

PART II 

LARYNX AND TRACHEA Page 124 

Injuries of the Larynx and Trachea. ' 

CHAPTER VIII 

ACCIDENTAL INJURIES INVOLVING THE CHEST, 

ABDOMEN AND BACK WHICH RESULT IN 

DISABILITY 

PART I 

CHEST Page 127 

Abrasions— Contusions— Incisions— Lacerations— Punctured Wounds— Burns 

and Scalds— Dislocation of the Sterno-Clavicular Articulation- Fracture 

of the Clavicle— Dislocation and Fracture of the Sternum— Dislocations of 

the Costal Cartilages— Dislocations and Fractures of the Ribs. 

PART II 

ABDOMEN • • ^'^^" 

Abrasions— Contusions— Incisions— Lacerations— Punctured Wounds— Hernia 

—Suppuration of the Inguinal Glands. 



xii CONTENTS 



PART III 



BACK Page 15& 

Abrasions — Contusions — Incisions — Lacerations — Punctured Wounds — Burns 

and Scalds — Fractures and Dislocation — Concussion of the Spinal Cord. 

CHAPTER IX 

INJURIES AND DISEASES OF THE MALE SEXUAE 
ORGANS AND SURROUNDING PARTS 

Page 175 
Abrasions — Contusions — Incisions — Lacerations — Cancer of the Penis or 
Testes — Epididymitis and Orchitis — Fistula in Ano — Gonorrhea — Hemor- 
rhoids — Hydrocele and Hematocele — Ischio-Rectal Abscess — Enlargement 
of the Prostate Gland — Injury to the Male Urethra — Urethritis — Vari- 
cocele. 

CHAPTER X 

ACCIDENTS AND DISEASES OF THE UPPER 
EXTREMITY 

PART I 

INJURIES TO THE SOFT TISSUES Page 201 

SHOULDER AND ARM — Abrasions— Contusions — Incisions — Lacerations — 
Punctured Wounds — Burns and Scalds. 

EILBOW AND FOREARM — Abrasions — Contusions — Incisions — Lacerations — 
Punctured Wounds — Burns and Scalds. 

WRISTS, HANDS AND FINGERS — Abrasions — Contusions — Incisions — Lac- 
erations — Punctured Wounds — Burns and Scalds — Palmar Abscess. 

PART II 

INJURIES TO THE ARTICULATIONS OF THE UPPER EXTREMITY 

Page 22a 
Sprains of the Acromio-Clavicular and Shoulder Joints — Dislocation of the 
Acromio-Clavicular Articulation — Dislocation of the Shoulder Joint — 
Sprains of the Elbow Joint — Dislocations of the Elbow Joint — Sprains of 
the Wrist Joint — Dislocations of the Wrist Joint — Sprains of the Hands 
and Fingers — Dislocations Between the Joints of the Hands and Fingers. 

PART III 

FRACTURES AND AMPUTATIONS INVOLVING THE UPPER EXTREMITY 

Page 241 

Fractures of the Scapula— Fractures of the Humerus— Amputations of the 
Upper Extremity— Fractures of the Radius and Ulna — Colles' Fracture — 
Amputation of the Forearm— Fractures of the Carpal Bones— Amputa- 
tions Through the Carpus— Fractures of the Meta-Carpal Bones— Frac- 
tures of the Phalanges— Amputations of the Phalanges. 



CONTENTS xiii 

CHAPTER XI 

ACCIDENTS AND DISEASES OF THE LOWER 
EXTREMITY 

PART I 

INJURIES INVOLVING THE SOFT TISSUES Page 259 

HIP AND THIGH— Abrasions— Contusions— Incisions— Lacerations— Punc- 
tured Wounds— Burns and Scalds— Contusions of the Knee Joint. 
LEG — Abrasions— Contusions— Incisions— Lacerations— Punctured Wounds- 
Burns and Scalds. 

FOOT AND TOES— Abrasions— Contusions— Incisions— Lacerations— Punc- 
tured Wounds — Burns and Scalds. 

PART II 

ACCIDENTS TO THE ARTICULATIONS OF THE LOWER EXTREMITY 

Page 282 
Sprains and Dislocations of the Pubic and Sacro-Iliac Articulations — Sprains 
of the Hip — Dislocations of the Hip— Sprains of the Knee Joint— Dislo- 
cations of the Knee Joint — Dislocation of the Patella — Dislocation of the 
Semi-Lunar Cartilages — Sprains of the Ankle Joint — Dislocation of the 
Ankle Joint — Sprains of the Foot and Toes — Dislocations of the Bones 
of the Foot and Toes. 

PART III 

FRACTURES AND AMPUTATIONS INVOLVING THE PELVIS AND 
LOWER EXTREMITY 

Page 306 
Fractures of the Pelvis — Fracture of the Femur — Amputation of the Thigh — 
Fractures of the Patella — Fractures of the Tibia and Fibula — Amputation 
of the Leg — Fracture Involving the Ankle Joint — Fractures of the Tarsus 
and Metatarsus — Amputation of the Foot — Fractures of the Phalanges 
of the Toes — Amputation of the Toes. 

CHAPTER XII 

ILLNESSES CAUSING DISABILITY 
DISEASES OF THE SKIN 

Page 327 
Furunculus — Carbunculus — Eczema — Felon — Herpes Zoster — Varicose Ulcer. 

CHAPTER XIII 

DISEASES OF THE BRAIN AND NERVOUS SYSTE^I 

Page 3o0 
Apoplexy — Epilepsy — Locomotor Ataxia — Progressive Muscular Atrophy — 
Spinal Hyperemia — Migraine — Acute Cerebral Leptomeningitis — Hemor- 
rhagic Pachymeningitis — Acute Myelitis — Neuralgia — Neurasthenia — 
Neuritis — Multiple Neuritis — O'ccupation Neurosis — Facial Paralysis — 
Sciatica — Spinal Meningitis — Sun-Stroke — Tetanus. 



xiv CONTENTS 

CHAPTER XIV 

• DISEASES OF THE CIRCULATORY SYSTEM 

Page 371 
Anemia — Angina Pectoris — Acute Endocarditis — Dilatation of the Heart — 
Leucocythemia — Acute Myocarditis — Chronic Myocarditis — Pericarditis — 
Phlebitis — Valvular Diseases of the Heart. 

CHAPTER XV 

DISEASES OF THE LUNGS AND RESPIRATORY 

SYSTEM 

Page 389 
Abscess of the Lung — Asthma— Hay Asthma — Acute Bronchitis— Acute Nasal 
Catarrh — Diphtheria — Emphysema — Hemoptysis — Influenza — Acute Ca- 
tarrhal Laryngitis— Congestion of the Lungs— Pharyngitis— Pleuritis— 
Catarrhal Pneumonia — Croupous Pneumonia — Pneumothorax — Acute 
Tonsilitis — Pulmonary Tuberculosis — Whooping Cough. 

CHAPTER XVI 

DISEASES OF THE DIGESTIVE SYSTEM 

Page 429' 
Appendicitis — Cholera Morbus — Acute Dysentery — Catarrhal Enteritis — Diar- 
rhea — Gastralgia — Acute Gastric Catarrh — Acute Toxic Gastritis — Gastric 
Ulcer — Intestinal Obstruction — Proctitis. 

CHAPTER XVII 

DISEASES OF THE LIVER 

Page 451 
Abscess of the Liver — Cholelithiasis — Carcinoma of the Liver — Cirrhosis of 
the Liver^ — Congestion of the Liver — Catarrhal Jaundice. 

CHAPTER XVIII 

DISEASES OF THE KIDNEYS AND BLADDER 

Page 463 

Acute Parenchymatous Nephritis — Chronic Parenchymatous Nephritis — 

Chronic Interstitial Nephritis — Cystitis — Pyelitis — Renal Calculi — Uremia. 

CHAPTER XiX 

FEVERS 

Page 477 
Cerebro-Spinal Fever — Dengue — Intermittent Malarial Fever — Remittent 
Fever — Pernicious Malarial Fever — Measles — Relapsing Fever — Scarlet 
Fever — Simple Continued Fever — Typhoid Fever — Typhus Fever — Yel- 
low Fever. 



CONTENTS XV 

CHAPTER XX 

MISCELLANEOUS DISEASES 

Page 503 
Ascites— Cholera— Diabetes Mellitus— Erysipelas— Gout— Hydrophobia— Par- 
otiditis— Peritonitis— Acute Articular Rheumatism— Muscular Rheuma- 
tism — Smallpox. 

CHAPTER XXI 

DISABILITY DUE TO POISONS AND GASES 
PART I 

MINERAL POISONS Page 527 

Antimony — Arsenic — Bismuth — Carbolic Acid — Copper — Hydrochloric Acid — 

Hydrocyanic Acid — Lead — Mercury — Nitric Acid— Phosphorus — Sulphuric 

Acid. 

PART II 

VEGETABLE POISONS Page 555 

Acetic Acid — Aconite — Belladonna-Stramonium-Hyoscyamus — Cocaine — Col- 

chicum — Ivy Poisoning — Mushroom Poisoning — Nux-Vomica-Strychnine — 

Opium and Morphine — Oxalic Acid. 

PART III 

MISCELLANEIUOS POISONS Page 574 

Acetanilid-Antipyrin-Phenacetin — Methyl Alcohol — Ammonia — Cantharides — 
Caustic Alkalies — Chloral — Iodine — Ptomaine Poisoning — Snake Poison- 
ing. 

PART IV 

GASES Page 590 

Carbon Dioxid — Carbon Monoxid — Hydrogen Sulphid. 

CHAPTER XXII 

ADJUSTING CLAIMS FOR DISABILITY RESULTING 
FROM ACCIDENTS OR DISEASES 

PART I 

ACCIDENT CLAIMS Page 597 

Definition of an Accident— Knowledge of Policy Forms— Early Adjustment- 
Manner of Adjustment— Provisional Settlement— Ability to Detect Fraud- 
ulent Claims. 

PART II 

HEALTH CLAIMS P^^'® ^^'' 

Definition of Disease— Knowledge of Policy Forms— Adjustment— Manner of 
Adjustment— Fraudulent Claims— Differential Diagnosis. 

PART III 
LIABILITY CLAIMS ^^^^ ^'^^^ 

Definition of Liability Examination— Competency of Examiners as Liability 

Adjusters. 



xvi CONTENTS 

CHAPTER XXni I 

METHODS OF SECURING APPOINTMENTS AS EXAM- | 

INER FOR INSURANCE COMPANIES AND WHEN | 

APPOINTED, HOW TO COMMAND EXAMINA- | 

TIONS IN COMPETITION WITH OTHER |: 

PHYSICIANS I 

Page 613 ' 

Becoming Well Known — Papers on Medical Subjects — Papers for Insurance ; 

Journals — Influence With Medical Director — Influence With Agent — ^ 

Writing Medical Director — Personal Acquaintance — Mutual Need — Ap- I 

pointments — Bureau of Information. t 

INDEX . . Page 625 \ 



CAUSES OF DISABILITY 



CHAPTER I 

ADVANTAGES OF MAKING ACCIDENT, HEALTH AND 
LIABILITY INSURANCE EXAMINATIONS 

Physicians throughout the United States are almost without 
exception anxious to make examinations for Hfe insurance com- 
panies and take every opportunity of securing appointments for 
the purpose of doing this class of work which is remunerative and 
at the same time can be done in conjunction with other profes- 
sional duties. Doctors who examine for these companies know 
that in making a life examination, the appointment is usually 
made by the agent and the examiner is expected to keep it, irre- 
spective of any inconvenience it may cause to himself or to his 
patients. They also know that an agent expects every risk to be 
recommended for acceptance and if not accepted by the home 
ofifice, the examining physician is blamed for not passing the in- 
dividual; the agent becomes very angry and if there is another 
examiner in the same locality, the doctor who has aroused ill feel- 
ings on the part of the agent simply because he has done his duty, 
is side-tracked and another physician is secured who perhaps will 
not be so conscientious in his work and efforts to protect the 
company. Yet with all these drawbacks and many others, physi- 
cians strive in every way possible to become examiners for life 
insurance companies and after getting an appointment continue 
to use every effort to secure examinations from agents. The 
great majority of doctors are not familiar with the demands for 
examinations by accident insurance companies and seem to think 
that the work is not as remunerative as that furnished by a life 
company. In this they are very much mistaken and many reasons 

1 



2 ADVANTAGES OF MAKING INSURANCE EXAMINATIONS 

can be advanced to show that examining for accident insurance 
companies is preferable in ahnost every way to examining for life 
insurance companies. 

DEMAND FOR EXAMINATIONS: Accident, health and 
liability insurance as sold to-day has been developed practically 
into its present proportions in the past fifteen years, and as this 
kind of insurance pays indemnity for disability due to an accident 
or disease, insurance companies doing this class of business are 
obliged to have medical examinations of individuals who have 
sustained an accidental injury or have suffered from an illness. 
This demand for examinations dates from the beginning of acci- 
dent and health insurance and is being increased every day on ac- 
count of the greater number of persons carrying this form of in- 
surance, and as the number of policies increase so also do the 
number of accidents and illnesses; consequently, the necessity for 
examinations by medical men is daily growing larger and this 
demand will continue for years to come, as every insurance com- 
pany Avill enlarge its business, some by spurts, others by gradual 
extension, but whichever way of extending the business prevails, 
the necessit}^ of having reports from medical men will be con- 
stantly on the increase. 

The number of examinations will also be increased on ac- 
count of the developments of the more rapid forms of transporta- 
tion which are now not confined as formerly to the large cities, 
l)ut may also be found in the smaller towns and even extending 
between towns and villages. The electric trolley, together with 
the large number of automobiles that are being operated through- 
out the country, tends to greatly increase the number of accidents; 
and as these accidents are the most complicated ones for insurance 
companies, the demand for competent medical examiners is 
greater. It is therefore very important that physicians prepare 
themselves to handle this class of work in a satisfactory manner 
and thereby increase their value, not only to the community at 
large, but also to themselves. 

TIME OF EXAMINATION : In examining for an accident 
insurance company, a physician is usually not requested to make 
.the examination until after the individual suffers from an accident 
or illness, and at this time the doctor knows positively that the 
claimant is either totally or partially disabled. If totally disabled, 
he is almost invariably confined to the house and can be seen at 
the convenience of the physician. If partially disabled, he is gene- 



URINARY AND MICROSCOPIC EXAMINATIONS 3 

rally attending to the inside duties of his occupation and there- 
fore can be found at his place of business and at a time which is 
convenient and suitable to the examiner for making, the examina- 
tion. As is well known in life insurance examinations, the doctor 
has to make the examination at a time convenient to the applicant 
or agent, the time of the doctor not being considered of any value 
whatever, and in many of these cases several visits are necessary 
before the examination can be made. Examinations for accident 
insurance companies can be made during the day in conjunction 
with other visits of the physician; thereby requiring less time and 
trouble than if the».examination was for a life applicant. 

URINARY AND MICROSCOPIC EXAMINATIONS: 
An accident examination rarely requires a urinary analysis, while, 
as is well known, this is almost invariably the case when the 
application is for life insurance, and in these cases the examiner 
must make the physical examination, secure a sample of urine — 
and this alone often requires the second trip — and then complete 
his report at his office or the office of the company when he ex- 
amines the specimen. Som.e life insurance companies even re- 
quire a microscopic examination of this excretion when the ap- 
plication is for certain amounts and do not allow any additional 
compensation for this work. A microscopic examination to be 
properly made requires from fifteen minutes to a half-hour, and 
this, with the time necessary for making a trip or trips for a life ex- 
amination and the time required for making it, counts up to more 
than an hour and the fee is seldom over Five Dollars. If this time 
would be employed for making examinations for accident insur- 
ance companies, the doctor could make several of them and 
double the amount of his pay. 

ANXIETY: Every physician in active practice is continu- 
ally worried more or less over his patients who are very ill and 
no sooner does he get some of these serious cases off his mind, 
than others come up and take their places. In life insurance ex- 
aminations, every applicant who is rejected or who passes only 
a fair examination causes considerable anxiety to the doctor, for 
the reason that he is constantly in fear of the agent taking his 
applicants to another physician and thereby cutting oft' a part 
of his income. In accident, health or liability insurance examina- 
tions, the doctor makes the examination and reports the exact 
conditions as he finds them and as soon as he sends his report, 
he is through with the case and has absolutely no reason to 



4 ADVANTAGES OF MAKING INSURANCE EXAMINATIONS 

worry about it or any complications that it may cause between 
the agent, the company or the claimant. Should the company 
decHne to pay indemnity, the doctor gets no blame, he has had 
no voice in deciding as to the liabiHty or merits of the claim and 
therefore he is not brought into any controversy with any one 
when indemnity is refused in any case. 

ACCIDENT INSURANCE PHYSICIANS WELCOME: 
Claimants expecting indemnity for accidents or diseases are al- 
ways glad" to see the examiner for the insurance company and he 
is welcome in every case; while in life insurance examinations it 
is a well known fact that physicians examining for these com- 
panies are often considered a bore, — as well as the agent — and 
sometimes are given scant courtesy. 

ADDITIONAL FEES IN COURT TRIALS : In liability 
insurance examinations there is always a chance that the case may 
reach a court trial and if it does, the insurance company almost 
invariably calls on the examining physician to secure additional 
information before the trial, and when this takes place he is sub- 
poenaed as an expert witness and in such cases is entitled to the 
fees usually paid for expert testimony in the locality in which the 
case is tried. This amount varies from Twenty-five to One Hun- 
dred Dollars per day. 

EXAMINATION BEFORE POLICY IS ISSUED : Acci- 
dent and health insurance companies frequently ask for an ex- 
amination of an individual before insurance of this character is 
granted, and in such cases the examining physician of the com- 
pany is requested to make the examination and report the exact 
condition of the individual as he finds it. In these cases, com- 
panies expect a recommendation from the doctor as to the desir- 
ability of insuring the applicant and this is the only time that 
the agent may become dissatisfied with anything that the physi- 
cian may do, as he may think that the applicant is a good risk, 
while the doctor after making the examination knows that the in- 
dividual is not insurable for the kind of insurance desired. These 
cases are not sufficient in number to be considered as even a 
slight disadvantage, while every case examined for life insurance 
comes under this category. Physicians who devote a consider- 
able part of their time to insurance work are capable of making 
three accident examinations in the same time required for one 
examination for life insurance. This is due to many reasons, the 
majority of which have been stated above. 



PHYSICIAN'S TIME 5 

PHYSICIAN'S TIME : Doctors in general practice are con- 
sidered public servants and to be successful they must be ready 
and willing to answer calls from old or prospective patients at 
any time of the day or night, and in cases of serious illnesses or 
accidents are expected to drop all other work and give attention 
to the one most needing it, which of course is perfectly right and 
proper, but nevertheless such a condition makes a doctor's life a 
burden, his time is never his own to devote to his family or to 
pleasure that he may desire for himself. If he is making a suffi- 
cient number of accident insurance examinations he can afford to 
let his younger or less fortunate confrere answer the calls of the 
ill and give his attention to insurance work, when he will examine 
cases during the day, sometimes in the evenings or Sundays, but 
every day he is master of his own time, coming and going as he 
wishes and should he desire to take a vacation of a day or a part 
of one, no one is in a position to say that he neglected a sick 
person, for such has not been the case. Physicians who have been 
in practice for some years and have then given it up for various 
reasons, consider this one of the greatest advantages gained in 
the change of occupation. 

INCREASING ACQUAINTANCE is to be desired by 
every physician who is practicing medicine, whether he is in gen- 
eral practice or confining his work to a specialty of some kind. 
The better known a physician becomes, the more practice does 
he secure in the line in which he is working and therefore any 
method which he takes to increase his circle of acquaintance will 
react to his benefit. Examining for accident insurance companies 
permits a physician to become known in various directions and 
with a class of people that he would probably have no way of 
meeting. Accident insurance as sold by most companies is placed 
among the best class of men in the community, and therefore 
when these persons suffer disability from an accident or disease, 
the examining physician of the company .makes their acquaint- 
ance and if he is at all aggressive, he can usually increase this ac- 
quaintance among the friends of the claimant by reason of having 
had an introduction from his company in making the examination 
for the accident or sickness, — as the case may be. This manner 
of increasing acquaintance also holds good with companies doing 
an industrial accident or health business in which the policy- 
holder pays for his insurance by the month; while these indi- 
viduals are not of the same social standing in the community, 



6 ADVANTAGES OF MAKING INSURANCE EXAMINATIONS 

nevertheless, a practice among any class of people is desirable and 
this acquaintance can be made to yield valuable returns if the 
examiner will make himself better known, after having once 
made an examination for his company. 

DIAGNOSIS AXD PROGNOSIS: Physicians examining 
for this kind of insurance and especially when they do any amount 
of this work, always become proficient in diagnosis and prognosis, 
as these are the two important points desired by an insurance 
company. AH companies expect their examiners to make a 
proper diagnosis on the first visit and at the same time they want 
a prognosis which is as nearly correct as it irs possible for a phy- 
sician to give. Physicians in large cities who do much of this 
work are always considered good diagnosticians and must be in 
order to hold their position with the companies they represent. 
The fact that a doctor does much of this work and becomes able 
to make a diagnosis in difficult cases assists him greatly in his 
private practice, as it is wxU known that after a diagnosis is made 
of an accident or disease, the treatment is not difficult. 

ADJUSTING: Physicians who examine for accident and 
health insurance companies and who become proficient in this 
branch of medicine, can develop themselves into adjusters for 
the companies they represent. Insurance companies find great 
difficulty in securing men who can properly adjust accident and 
health claims; therefore, a physician who is a competent examiner 
and can make a proper diagnosis and estimate the length of time 
that disability will last, can make a good adjuster if he has any 
tact and business training. He already has an advantage over an 
individual who is not skilled in medicine and all he need do is to 
develop the part required for adjusting a claim. If a doctor 
learns this part and can adjust accident and health cases, — even 
though he does not have authorit}^ to pay the claim — he becomes 
of much more value to his company. Physicians who examine 
for accident insurance companies develop themselves into ad- 
justers by recommending to the company the time that they con- 
sider the individual is justly entitled to. If this judgment is cor- 
rect in the majority of cases, the company soon learns to depend 
on any recommendation oft'ered and in time the doctor will be 
permitted to adjust small claims, and authorized to draw sight 
drafts in settlement of them. The amount of these drafts will 
usually be limited to a small figure at first, but as experience is 
gained, the limit is raised until the doctor is adjusting and paying 



COMPENSATION 7 

accident claims of any amount. When a physician is able to ad- 
just and settle accident or health claims for an insurance company 
and is permitted by his company to do this part of the work, he 
has a higher standing with his company than a physician who 
simply makes the examinations, and is better able to protect his 
interests and retain the examinations than if he was not com- 
petent to make the adjustment at the same time A doctor who 
adjusts for an accident insurance company is so well intrenched 
with his company that it is almost an impossibility for another 
physician to secure any examinations from that company, — pro- 
vided the examiner continues to do his work in a satisfactory 
manner. Physicians who are competent to adjust cases for one 
company soon get a reputation among all companies of being 
able to do this work and are frequently asked by other companies 
to make an examination, and adjustment if possible, when the 
company has its own examiner. It will thus be seen that a doc- 
tor who takes up this work and becomes a good examiner and 
then in turn develops into an adjuster, is sure of holding the work 
with the company which he represents and is also in line to in- 
crease this work by the reputation he gets from his ability to 
examine and adjust properly the different cases that he sees. 

COMPENSATION : Insurance companies of all kinds pay 
for any services rendered them at the end of thirty or ninety 
days; therefore, a physician who is examining for insurance is 
sure of his pay and does not need to count on collecting only a 
certain percentage of it. Doctors practicing medicine in different 
parts of the country collect from twenty-five to seventy-five per 
cent, of their bills; while with work from an insurance company, 
they are sure of collecting one hundred per cent. Life insurance 
companies usually pay from Two to Five Dollars for ordinary ex- 
aminations; while accident insurance companies seldom pay more 
than Two to Three Dollars for each examination. Even though 
an accident company does not pay more than Three Dollars, yet 
a physician who is doing this kind of work is capable of making 
more money than if he was examining for a life companv. Acci- 
dent insurance examinations are made during the day at a time 
convenient to the ph3^sician and usually do not require more than 
ten to fifteen minutes and probably very little time is necessarv 
in arriving at the place of the examination, as his work often 
takes him in the vicinity in which the claimant lives: while in a 
life insurance examination, althou^-h he mav o-et a Five Dollar 



8 ADVANTAGES OF MAKING INSURANCE EXAMINATIONS 

fee, he must make one or more trips for the examination, do the 
work at a time usually inconvenient to himself and often must 
leave his office during office hours while he has patients waiting 
for him, not only taking a chance of not being able to make the 
examination, but also losing the amount that he would receive 
from his office practice. The advantage of doing accident, health 
and liability examinations is so much greater than making ex- 
aminations for life insurance companies, that it seems if physicians 
were familiar with all these advantages, they would endeavor to 
secure more of this work than they do, thereby materially increas- 
ing their income and enlarging their reputation among insurance 
companies and the community in which they practice medicine. 



CHAPTER II 

NECESSARY QUALIFICATIONS FOR A SUCCESSFUL 
INSURANCE EXAMINER 



It might be supposed that any physician would be competent 
to make an insurance examination; a great many are, but the 
vast majority neglect to ascertain one or more of the important 
details and the examination is of lessened value to the company 
that requests it. If a doctor expects to make many examinations 
he must be able to make them in a satisfactory manner, pleasing 
the company, the agent and the claimant. To do this he must 
possess many qualifications in addition to his medical education 
and must know by study or experience, all the important require- 
ments of an examination. Ability to use his education and experi- 
ence in making an examination and report that will be a credit 
to himself and of value to the company is very necessary. Many 
physicians possess the following described qualifications, few use 
all of them, while all could use every one of them to advantage. 

PERSONAL APPEARANCE of a physician in active prac- 
tice in any part of the United States demands that careful atten- 
tion be given to all details which will improve his standing in the 
community in which he resides. It is a conceded fact by success- 
ful business men in all the large cities, that dress is the most im- 
portant part of a man's personal appearance. A physician who 
keeps his clothes clean, pressed and presentable, is well dressed, 
even though the clothes are not of the latest pattern. He will 
command more attention and more respect from strangers whom 
he meets accidentally and through friends and business associa- 
tions, and also among his own close personal friends, than will 
one who is slovenly in dress without regard to whether he makes 
a neat appearance or not. A physician should not only dress well 
but should also wear clean linen and as laundry bills even in large 
cities are not excessive at the present time, there seems no excuse 
for a man to wear shirts, collars and cuffs that are soiled and unfit 
for wear among other wxll dressed and educated people. 



10 QUALIFICATIONS OF AN INSURANCE EXAMINER 

Many physicians are extremely busy and employ more than 
the usual number of hours for attention to business; even in such 
cases a doctor who is careful of his personal appearance will not 
appear with his face covered with one or more day's growth of 
beard, when he should be shaved daily. The importance of being 
well dressed, — and by that is meant the wearing of good clothes 
which fit the body properly, keeping them clean and pressed and 
the use of clean Hnen at all times — is something that should not 
be overlooked by any one, let alone a physician who needs all the 
assistance he can command in the practice of his profession. It 
is well known that a patient's confidence in his doctor assists very 
materially in a return to health and this confidence is strengthened 
Avhen the physician is always properly and cleanly clothed. Even 
if a doctor cannot afford to wear the latest cut of clothes he can 
keep the ones he has and his linen clean, and that alone is suffi- 
cient in many cases. When it is necessary to meet strangers fre- 
quently — and such is the case in accident, health and liability work 
— it is absolutely imperative that the doctor be well dressed and 
make a favorable impression on the first visit, as by dress most 
men are first judged. 

AGE often determines whether a man will be appointed as 
an examining physician by an insurance company. It is therefore 
important that this be made known to the company when an ap- 
plication is sent in requesting an appointment as the examining 
physician or surgeon for a certain locality. Insurance companies, 
either in the person of the medical director or some one who 
has the power of appointing the examining physician or surgeon 
throughout the part of the country in which the company writes 
business, pay close attention to the age of the applicant. Physi- 
cians who are from twenty-five to fifty years of age are more often 
selected to examine than are men who are younger or older than 
these ages. There should be no age limit for an examiner, and 
there probably is none, when the physician has been an examiner 
for a company for some years or more and his work has been 
entirely satisfactory. Even though he grows old, it is fair to as- 
sume that his services will be continued unless there are other 
reasons than age for declining them. 

GRADUATION: Possession of a literary degree, a high 
school diploma or an equivalent to either of these, is considered 
valuable to any man w4io expects to study medicine, and those 
who have a good preliminary education are judged to be better 



EXPERIENCE 11 

able to make an examination and report brietly and in a concise 
manner, the result. An insurance company should know the date 
of graduation from a medical college of all its examiners as the 
medical director, if possessed of this knowledge, is better able to 
judge the standing and ability of his examiners than if such is not 
known. He will usually put more confidence in reports from meii 
who have received a good preliminary education and are then 
graduated from a reputable medical college. 

Physicians who are graduates of the regular or allopathic 
colleges are more often selected for these appointments than are 
others. This is especially true in large towns and cities where an 
insurance company has the choice of men. In the smaller towns 
and villages graduates of the smaller medical colleges and also 
those who are not from an allopathic college are sometimes se- 
lected for appointment, and in many cases the work proves satis- 
factory to all concerned. 

EXPERIENCE in the practice of medicine is absolutely 
necessary before a physician can make a good insurance ex- 
aminer. It makes little difference if this experience has been re- 
ceived by hard work in private practice extending from a few to 
a number of years, or if it has been secured while acting as a resi- 
dent physician in a hospital. At the present time it seems that a 
doctor who has graduated from one of the medical colleges in 
the United States and has then served as a resident physician in 
a hospital of a large city, is better qualified than a young man 
who has graduated and immediately commenced private practice. 
A doctor who has served two years as a resident physician and sur- 
geon in a hospital and has had from one to three years of private 
practice after leaving there is considered better qualified for mak- 
ing examinations for insurance companies, either in the accident or 
life department, than is a recent graduate or one of the older 
members of the profession. Insurance companies usually select 
a doctor for an examiner who can fill these last requirements. 

A SPECIALTY is often developed by physicians in not only 
the large cities but also the smaller ones and this increased 
knowledge that a doctor possesses on any subject must of neces- 
sity serve him a better purpose Insurance companies do not con- 
sider that a physician should be a specialist in any branch of his 
profession in order to make the usual examination as required 
by them, but it will often increase his standing with his brother 
physicians and also the company when he is called upon to ex- 



12 QUALIFICATIONS OF AN INSURANCE EXAMINER 

amine a case in which this special knowledge can be used and it 
may be of decided benefit to him. It is not a necessary qualifica- 
tion, but a desirable one in many instances. 

TACT is more essential in a physician's work and especially 
in one who is examining for an insurance company than almost 
any other part of his education, except of course the medical one. 
This mental perception instantly teaches a doctor how to judge 
the person about to be examined and tells him by intuition the 
manner of examining the claimant, what to say and when to say 
it. Tact is considered by many men as simply an ability to read 
human nature at a glance and apply this ability in gaining the ob- 
ject desired. No matter what the definition of this word may be,* 
it means that a physician to be a successful insurance examiner 
must possess it and use it in every case that he examines. It 
teaches him in some cases to be smooth, gentle and easy in his 
manner and talk, while in others he must be just the opposite — 
brusk, abrupt and loud. He must have the ability to know the 
proper time for use of these different moods; when to change 
his manner, how to change it and exactly what to say under dif- 
ferent conditions; always gaining his point without giving ofifence. 
It is one of the most valuable assets that any man may possess, 
be he a physician, minister, business man or even a laborer. By 
being a good judge of human nature, a master in the emplcyment 
of tact, he not only smooths his own pathway, but also leaves 
behind him gentleness and kindness wherever he goes. 

METHOD : Every physician who expects to be very success- 
ful must attend to his work in a methodical manner, and this is 
also true in making an insurance examination, as there is so 
much to be done and so many questions to be asked, that it is 
absolutely essential that a certain system be followed. If this is 
not done a doctor is almost sure to forget to ask an important 
question or omit examining a certain part of the body which 
should be examined and reported upon. Experience teaches phy- 
sicians who are doing much examining for insurance companies, 
that they must have a well established procedure for all cases, but 
as practically all insurance companies furnish a blank to be filled 
in by the examiner, this blank furnishes a base for the examina- 
tion. All blanks, however, are not complete, as it would be im- 
possible to design one that would meet all requirements. If a 
blank is furnished, the examining surgeon must secure answers 
to all the questions on it and when that is finished he should take 



ACCOMMODATING 13 

up different lines of questioning which his judgment and experi- 
ence teach him are important to the particular case that is being 
examined. If a blank is not furnished for an accident examina- 
tion, there is certain information that the company expects, such 
as the name of the claimant, the age, height, weight, residence, 
occupation, date of accident with a short history as to the cause, 
where it occurred, together with the length of house confinement 
and the duration of total and partial disability. If the examination 
is of an individual disabled by illness, the company expects all of 
the above, substituting however, for the date of accident and its 
history, the date of the beginning of illness, together with the 
signs and symptoms and the length of house confinement. It is 
also well to give the name of the attending physician and his ad- 
dress and any other information which would be of use to the 
company regarding the particular case under consideration. 

ACCOMMODATING: In making examinations for an in- 
surance company, several parties must be considered, the com- 
pany, the agent, the person to be examined and the examiner. 
The company expects the examiner to oblige the agent by mak-' 
ing the exarnination at the earliest possible moment consistent 
with the wishes, the residence, the occupation, etc., of the claim- 
ant. In making examinations for accident, health or liability in- 
surance the company often gains by not having the examination 
made until a few days after the accident has occurred. In such 
cases if the physician will explain the condition to the agent, — ■ 
when the examination has been requested by him, — it is often 
possible to postpone it one or two da3^s, and, by doing so, the phy- 
sician can arrange his own work and make the examination at a 
more suitable time to himself. Sometimes the attending physician 
who has been consulted before an examination is to be made in 
an accident case, will request that the dressings be not removed. 
In such cases, unless there is a suspicion that the claim is a fraudu- 
lent one or it is absolutely necessary for any other reason, the ex- 
amining surgeon should respect the wishes of the attending phy- 
sician by conforming to his request. If the examiner will accom- 
modate all parties concerned in an insurance examination, consid- 
ering himself the last one to be obliged, he will find that his repu- 
tation is enhanced and his work will thereby show a considerable 
increase in this line. 

PROMPTNESS in making an examination when an indi- 
vidual has been reported as suffering from an accident or illness. 



14 QUALIFICATIONS OF AN INSURANCE EXAMINER 

is one of the most desirable qualifications of an insurance ex- 
aminer and might almost be said to be the principal one, as no 
company will continue the services of any physician when his ser- 
vices are rendered three, five, seven or ten days after a request 
has been made for an examination. Many physicians do not seem 
to realize this point and when a company or an agent asks that 
an examination be made, they pay no attention to it until some 
days have passed and then most likely when they do make the 
examination, evidences of the accident have disappeared, if the 
case be one of accidental injury, and if an illness, the acute signs 
and symptoms which would serve to make a differential diagnosis 
have ceased to exist. When an accident happens to an individual, 
the company may not receive notice until several days have 
elapsed after the accident occurred. After the notice has been 
received, one or more days are usually required at the home office 
in getting, out a letter of request for an examination to the doctor 
and then additional time is required for the letter to travel be- 
tween its origin and its destination. It can therefore be seen that 
when an examination is requested by a company located, as for 
example in New York and the accident or sickness disables an 
individual who resides some distance from the home office, that 
considerable time has alread}^ elapsed before the company can get 
word to its examining physician to make the examination, and he 
must be very prompt in visiting the case for the purpose of seeing 
any signs of an accident, and especially those of a more trivial 
nature, if he expects to be able to report having seen the actual 
evidence of the injur3\ This applies more forcibly to diseases, the 
signs and symptoms of w^hich change and disappear very quickly. 
Neglect on the part of physicians in making an examination at 
once when requested is well known, and often commented upon 
adversely at the home office. Frequently the report of an exami- 
nation is received at the home office of a company from seven to 
fourteen days after it has been requested, and in many cases the 
claim has already been settled, and in such cases the company has 
absolutely no need of the report of the examination. A doctor 
cannot become a successful insurance examiner unless he is 
prompt in making examinations that are requested by insurance 
companies. If he receives in the morning mail a request for an 
examination of an individual, he should see and examine the party 
on the same day and after the examination is made his work 
should be completed by getting his report off promptly, — in the 



CONCISENESS 15 

next outgoing mail if possible. By so doing, the report will not 
only be of much service to the company, but what is more im- 
portant to him, his work will be satisfactory and in a short time 
he will be the doctor who not only receives requests for all the 
examinations from that company, but also is being asked to make 
examinations for other companies. 

CONCISENESS in talking or writing is something that 
should be acquired by every one, and it is especially desirable in 
reporting examinations to insurance companies. A physician who 
can make an examination in a short time and report it briefly and 
concisely without leaving out any of the important information 
that he has secured, is the one desired by insurance companies. 
It must be remembered that the person at the home of!ice, — 
either the medical director or the claim examiner, — is a busy man 
and he has many reports to read, not only on one day, but every 
day, and he is sure to favor an examiner who can make a thorough 
examination and just as thoroughly report it in the proper 
manner. On account of so few physicians possessing this qualifi- 
cation, insurance companies have been compelled to use a blank 
form that may be sent out and filled in by the examining physi- 
cian. This form assists the examiner in attempting to get all the 
important points or information that may be derived from the 
examination and also makes the report more brief than if the phy- 
sician had been allowed to write a letter concerning the case. Phy- 
sicians who are not connected with the home office of an insurance 
company or placed in a position where they have an opportunity 
to look over the work of others, do not know how much time can 
be gained by a medical director in a home office when he is en- 
abled to read reports which are well formed grammatically and 
at the same time brief and to the point. 

RELATIONS WITH AGENT: A successful insurance ex- 
aminer is one who can always be on good terms with any agent 
that the company may place in charge of its office. To have a 
good feehng existing between the agent and the doctor is neces- 
sary, just the same as it is necessary to have harmony between 
different officers of a company if that company expects to be suc- 
cessful. It is not expected or required of a doctor that he be a 
personal friend of an agent, but he should be pleasant, affable and 
willing to accommodate the agent in making the examination 
promptly or in keeping an appointment which has been made by 
the agent for him, even though it may be somewhat inconvenient. 



16 QUAI.IFICATIONS OF AN INSURANCE EXAMINER 

The company also does not desire that any personal relations 
which may exist between the doctor and the agent, may cause the 
doctor to favor the agent in making his reports of examinations; 
in other words, no matter in what position he finds himself with 
the agent, he should remember that he is employed by the com- 
pany and is expected to furnish them with a report of an exami- 
nation which is unbiased by any local conditions. This is often 
very difficult, especially in the smaller towns and villages where 
the doctor may be well acquainted with the agent and also be a 
close personal friend. He, however, should guard himself against 
these conditions and endeavor in every way possible to furnish his 
company with a true report of the conditions as he finds them; 
by so doing his services become very valuable to a company, for 
the simple reason that the company can depend on anything he 
says. 

INSPECTION : To learn by inspection is only acquired after 
long practice and close attention to details. However, it is a very 
valuable asset to any physician w^ho attempts to examine accident 
or health cases for insurance companies. If he is able to take in 
at a glance many Httle things that he sees, not only about the 
claimant but also concerning his surroundings, his mode of life, his 
friends, his actions, etc., he will greatly increase his efhciency to 
the company and to himself. This ability to judge conditions at 
first sight is extremely essential in one who is doing this kind of 
work, as very often when he first sees a case, his suspicions are 
frequently aroused over some action or other little detail that 
would not be noticed by an ordinary observer, and he is put on his 
guard and probably by this ability a fraudulent case is not over- 
looked. 

AGE, HEIGHT AND WEIGHT is almost always demanded 
in a report of an insurance examination. There are many reasons 
for this; perhaps the most important one being that the medical 
director can compare the report of the examiner with the appli- 
cation and is thereby enabled to ascertain if the individual ex- 
amined is the same one who applied for and was granted insur- 
ance. It is therefore important that the examiner judge accurately 
the age, height and weight of the person he examines. The 
majority of people can estimate fairly well the age of others, but 
all cannot tell the height and weight of individuals. For this 
reason it is advisable that the examiner ascertain the exact height 
of the person he examines, and this can only be done by meas- 



DIFFERENTIAIj DIAGNOSIS 17 

uring. It is a very easy matter to carry a tailor's tape measure 
or even a metal one and always be prepared to measure the height 
of any claimant. For the purpose of being better able to judge 
the height of an individual, — when a tape measure is not at hand, 
— it is well that the physician himself knows the exact distance 
from the floor to his ovm shoulders, his chin, mouth, eyes and top 
of the head. If he is familiar with these different distances, he is 
able to decide the height of almost any one within an inch, and 
if he can judge the height as near correctly as this, his judgment 
on this part of his report becomes of value even though he has 
not measured the individual. 

If possible all cases should be weighed and the exact weight 
of the individual reported to the company, but as is well known, 
this is impracticable in a number of cases, and the physician must 
guess at the weight. By knowing the exact weight of himself, and 
also of some of his immediate family and friends, in comparison 
with the height, he can estimate well enough for the purpose of 
reporting an examination of an accident or health risk. 

DIFFERENTIAL DIAGNOSIS : Ability to make the diag- 
nosis between two or more diseases, especially when they resemble 
each other, is acquired by physicians at different stages of their 
career. Some doctors are more proficient in this branch of the 
profession than others, and can readily make the differential diag- 
nosis when called upon to do so. Others acquire this skill only 
after long practice, but whether learned in the early part of a 
physician's career or not, it is extremely valuable to him, as he 
is thereby enabled to better make the diagnosis of all accidents 
and diseases in his private practice and in consequence give his 
patients better treatment from knowing the exact cause of the 
disability. The fact that he possesses this talent enables him to 
give better service to an insurance company, as in practically all 
cases he has only one opportunity to make the diagnosis. By 
this is meant, that the company requests the examination of an 
individual and pays the doctor for one visit. If he is not able to 
make the diagnosis at the first visit and must go the second or 
third time, he does so at a proportionate reduction in his fee, be- 
cause the company only pays him for one trip. It is therefore ex- 
tremely important that he be able to make the diagnosis of an ill- 
ness at the first visit; and also to differentiate between fractures 
and dislocations and other accidents. If he is very proficient in 
this branch of his profession, he will in most cases detect a fraud- 
2 



18 QUALIFICATIONS OF AN INSURANCE EXAMINER 

ulent claim, and this is one of the principal objects of his examina- 
tion. Fraudulent claims are frequently made on all insurance 
companies, and this is more often true when the claimant belongs 
to the lower classes or is one of the numerous foreigners who now 
make up a large part of the lower laboring classes of this country. 
Even though they are undesirable risks, they are insured, and 
naturally, when once insured, have claims, and the examiner must 
be able to detect fraud whenever it is attempted. 

CROSS-EXAMINATION OF CLAIMANT: This is one 
of the parts of an examination that a doctor is sometimes called 
upon to undertake. When he examines an individual of more 
or less standing in the community and in which there appears no 
possible reason to cheat the company, it is necessary for him to 
be able to cross-examine the claimant zvithout tJie claimant's 
knozdedge. When he examines persons who are making claims 
for accidents or illnesses, and these persons come from the lower 
walks of life, it is very necessary that he be able to use his knowl- 
edge in preventing the attempt on the part of the claimant in 
many cases to conceal or misrepresent facts. The cross-exami- 
nation of such claimants is of no use at all if the physician is not 
able to do this without the claimant's knowledge. A physician 
with his medical education is at a great advantage when he at- 
tempts to cross-examine some one who is concealing facts, for 
the reason that his medical education has given him the proper 
signs and symptoms of accidents and diseases, and even though 
the claimant may state that he suffers from different symptoms, 
a physician should be able to make the claimant admit in other 
ways by answering certain questions that he has contradicted him- 
self. The cross-examination of individuals of the higher walks of 
life, when an attempt is made to foster a fraudulent claim upon 
the company is much more difficult. In these cases, — which, for- 
tunately, are few, — a physician has not only to combat a man 
with perhaps the same literary education as himself, but also one 
who has studied the principal signs and symptoms of the accident 
or disease from which he claims to be suffering. It therefore be- 
comes much more difficult in these cases and the chances of the 
physician detecting a fraudulent claim become less. In such 
cases when the examiner suspicions that the claimant is making a 
fraudulent claim, the company will usually authorize and pay for a 
second or third examination, if it is possessed of the facts or sus- 
picions of its examiner. 



IMPARTIAL REPORTS 19 

IMPARTIAL REPORTS : In making a report for an insur- 
ance company of an examination, the examiner should be particu- 
lar that his report is fair to all concerned. He should report the 
conditions exactly as he finds them and not allow his personal 
feelings to enter into the matter at all. It is very difficult for 
some physicians to do this, as their relations with the party ex- 
amined may be so close that it is almost impossible not to favor 
the claimant. Such a condition, however, must be constantly 
guarded against and every endeavor made to report the findings 
of the examination precisely as they exist. An insurance com- 
pany can act with more justice to the claimant, if its examining 
surgeon reports the case exactly as he finds it and does not attempt 
to discolor his remarks in any way, either favorable to the com- 
pany or the claimant. This abihty to report exactly the condition 
as found, if not possessed by the doctor, should be cultivated 
by him and in time his reports will become more valuable to the 
companies for which he is working. 

EXPLANATIONS: Practically all companies when re- 
questing an examination from a physician, send out a blank report. 
These reports should be answered by being filled in by the ex- 
amining physician in his own hand writing and in ink and each 
question answered at the time and place where the examination 
is made. These points are very important, and usually all com- 
panies will return a blank which is not filled in by the examining 
surgeon in ink and all the questions properly answered. If the 
examiner deems it impossible to reply to one or more of the ques- 
tions, he should indicate in some manner that he has seen the 
question and cannot answer it, such as a check mark or a small 
horizontal line. By treating the question in this manner, the per- 
son at the home office who reads the report knows that the 
examiner has seen it. However, as all questions are put on the 
blank for a special purpose, it is very poor judgment on the part 
of the examiner to neglect answering any of them. Every one 
should be answered in some way, even if a note of explanation 
has to be added to the report and this can generally be done under 
the subject of ''remarks" which usually ends all blanks. 

GOOD IMPRESSION BY EXAMINER: Individuals who 
can meet strangers either by a personal introduction or through 
the needs of business should be able to make a friend out of every 
person thus met. On account of the character of the work of a 
medical examiner, and especially in examining for accident. 



20 QUALIFICATIONS OF AN INSURANCE EXAMINER 

health and liabiUty msurance, it is essential that the physician 
makes a good impression, and when he leaves that the person 
whom he has examined will not only think well of his ability as a 
medical man, but also consider his personality perfection itself. 
Insurance examinations require that a physician develops to a 
high degree many traits of character and action that place him 
beyond his usual associates. Ability to examine a person who is 
opposed to the examination and who hinders the examiner in 
many ways, is only acquired after much practice, but when once 
acquired, an individual who has received the examiner in an un- 
courteous manner, will have his opinion entirely changed when 
the examination is over, and will not only speak favorably of the 
physician but will also wilHngly permit a future examination at any 
time if necessary. When a physician has changed the attitude of 
a claimant by leaving behind him a good impression, he assists 
the adjuster of the company very much when the time arrives 
for the settlement of the case. All persons making claim.s under 
accident and health policies must be examined and treated in 
the most courteous manner possible; the doctor remembering 
that the injured party has taken out his accident or health in- 
surance only after earnest solicitation on the part of the agent, and 
unless the examination is properly made and the claimant left in 
a satisfied frame of mind, the agent is almost sure to lose the 
policy at the next renewal, and when he loses a renewal he loses 
a commission which means to him a certain amount of dollars and 
cents, and just as soon as he has occasion to have his pocket 
touched by untactful work on the part of an examiner, just so 
soon will be begin to make complaint of the doctor's work and 
endeavor to have another examiner appointed. In liability ex- 
aminations the injured party is not insured and the company in 
making a settlement does not care if the party is satisfied or not; 
but this condition of affairs does not excuse the doctor who makes 
the examination, if he be rough or discourteous in any manner 
whatever. 

THE RESPONSIBILITY of an insurance examiner is very 
great on account of the multiple duties that are required when 
making an examination. It is necessary that nothing be over- 
looked, as the company may demand information upon it at a 
later date. All information that is acquired during an examina- 
tion must be transmitted to the company as soon as it is received, 
as it is impossible to tell at the time of the examination whether 



4 



PEES AND BILLS 21 

the case will reach a court trial or not. Physicians are responsible 
to the company for their work and the company in return is re- 
sponsible for their acts toward the claimant. It is therefore highly 
important that these facts be recognized and that the examiner 
do nothing that may reflect in any way upon the company or 
place the company in any position that it may be liable for 
damages for his acts. 

FEES AND BILLS : Physicians are usually paid a certain 
fee which is either agreed upon before the examination is made 
or the usual price which is paid in the locality in which the ex- 
amination is held, is allowed, consideration being given to the 
distance that the doctor is compelled to go in making it. Insur- 
ance companies generally pay very well for the services they de- 
mand and they should receive the most complete report that an 
examiner is capable of getting. In some of the large cities, physi- 
cians are em.ployed on a salary, and for a certain stipulation agree 
to make all the examinations that are necessary. When the ex- 
aminer is paid for each individual examined, the company in al- 
most all cases pays for the services rendered and usually the check 
is sent from the home office. 

It is always well in presenting accounts for collection to an 
insurance company, that each account be made out separately; 
and most companies request that bills be presented to them 
monthly; if not at the end of thirty days, accounts should be pre- 
sented at least every three months. If delay is had in presenting 
these accounts, the claim is usually settled and filed away and a 
certain amount of labor is required at the home office in searching 
for the papers and checking ofT the doctor's bills. Many insur- 
ance companies file all the papers connected with each individual 
case in a separate envelope, therefore they insist on a separate 
bill from the physician for each examination that he makes. Not 
only do insurance companies desire and benefit from the proper 
and systematical presentation of bills, but also the examiner as 
well, as he receives his money soon after his services are com- 
pleted, something that does not frequently occur in private prac- 
tice. 



CHAPTER III 

EXAMINING FOR ACCIDENT INSURANCE COMPANIES 

PART I 

ACCIDENT EXAMINATIONS 

If an individual carries an accident insurance policy and suf- 
fers from an accident, he should immediately notify the company 
that he has been injured. These notifications, however, are not 
always sent at once, sometimes being delayed from a few days to 
several weeks and sometimes not even sent until after all evidence 
of the accident has disappeared and the party has returned to 
work. When an accident insurance company receives notice that 
one of its poHcy-holders has been injured and that total or partial 
disability is present, it is the custom of the majority of companies 
to have the party examined by the examining surgeon who is no- 
tified either from the home ofhce or through the agent and re- 
quested to make an examination of a certain individual whose 
name and address is given him. On receipt of such information, 
the doctor is expected to see the injured party, make the exami- 
nation, and send in a report at once. A number of points must 
be considered by the physician who makes this examination, and 
the following are the important ones : 

PURPOSE OF EXAMINATION: Insurance companies 
are compelled to have an examination made of the policy-holder 
when that person becomes a claimant, for the simple reason that 
they cannot always depend on receiving a report from the attend- 
ing physician; and even when a report is received promptly from 
the physician, in many cases he does not reply to all questions on 
the blank or if he answers them, a number are answered in an 
evasive manner or in such a way that the company is led to believe 
that certain information which might be valuable to them is with- 
held. On this account it is necessary that the company's examiner 

23 



24 ACCIDENT EXAMINATIONS 

see the claimant, and make a full report of the exact condition as 
found to be existing. 

PLACE OF EXAMINATION: It must be remembered 
that an individual who carries an accident insurance policy has 
done so in almost every case only after he has been asked and 
importuned many times by the agent; therefore, when he suffers 
from an accident, even though he expects to get some of his 
money back, — as the expression is, — he demands and so also does 
the agent, that the examination be made at a place most con- 
venient to the policy-holder, and this place is either his home or 
his place of business. AMien a person is totally disabled, he can 
always be found at his home; when partially disabled, he may be 
found there or attending to some part of his business w^hich may 
require his presence on the street or in his ofifice. If the party is 
totally disabled and confined to the house, the question as to the 
place of examination is easily decided. If he is only partially dis- 
abled and is attending to a part of his business, it is necessary 
to ascertain in some way where the claimant can be seen and ex- 
amined, and this can usually be best done by telephoning and 
making a definite appointment for the examination. It is always 
best to examine the individual at his home or place of business, 
as very few policy-holders will accommodate the doctor and call 
at his office or at the ofhce of the insurance company for examina- 
tion. If the examiner will always accommodate the agent and 
the policy-holder by making th'e examination at a time most con- 
venient to the claimant and at his home or place of business, he 
will strengthen his relations with the agent, and usually be favored 
with the majority of the examinations from the office over w^hich 
the agent has control. 

EXAMINATION WITHOUT ATTENDING PHYSI- 
CIAN : Professional courtesy among physicians demands that a 
doctor in making an examination of another ph3^sician's patient, 
do so in the presence of the attending physician, but this cannot 
always be accomplished by an insurance examiner. If he at- 
tempted to examine every insurance case in the presence of the 
attending physician, he would soon find that he was making one 
to two or three examinations only per day. This method of pro- 
cedure can usually be carried out in the smaller towns, but it is 
an impossibility in the large cities where a physician examines 
for a number of companies and must necessarily see these cases 
at the convenience of the policy-holder and with some regard for 



EXAMINATION WITH ATTENDING PHYSICIAN 25 

his own time. The poHcy which is held by the claimant contains 
a clause giving a medical examiner of the company "the right 
to examine him at any time and as often as he may deem it 
necessary." It can thus be seen that the examining physician is 
protected and has the right to make an examination of a policy- 
holder who has been injured, at any time that he desires. Pro- 
fessional courtesy should be observed whenever possible, but when 
that courtesy interferes with business, it must necessarily be set 
aside. 

EXAMINATION WITH ATTENDING PHYSICIAN: 
At the time the company is notified that one of its policy-holders 
has been injured, it is occasionally requested that the examiner 
make the examination in the presence of the attending physician. 
Whenever this is done, it is always well to accede to the wishes 
of the claimant and endeavor to make the examination as desired, 
and arrange an appointment with the attending physician for this 
purpose. Very often he will state that he has no desire to be 
present and request the examining surgeon to proceed without 
his presence; in which case the examination can be made and the 
claimant told that his attending physician authorized the examina- 
tion and stated it was not necessary that he be present. Requests 
that the attending physician be present at the examination are 
sometimes made with the intention of delaying it. These occur- 
rences, of course, are only seen in attempts at frauds, and great 
care must be exercised by the examiner in deciding if he will 
make the examination at once without the presence of the at- 
tending physician, — as he has a perfect right to do, — or wait until 
he can make an appointment with him. 

EXAMINATION : In order that an examiner for an insur- 
ance company may make as many examinations as possible and 
thus use to good advantage each day, he should have a certain 
routine method of procedure well fixed in his mind and follow 
this in every case. If he does this he will make a much better 
examination, consume much less time and send in to the com- 
pany a report which is rarely lacking in anything that might be 
desired. If a blank has been furnished for the report of the ex- 
amination, it is best to ask each question in its turn and secure 
an answer from the claimant, writing down his answer in his own 
words as near as possible, and at the time of the examination. 
Some physicians examine a case and then fill in the report at their 
of^ce. This is a very poor custom, as in almost every case the 



26 ACCIDENT EXAMINATIONS 

doctor is unable to fill in some part of the report, and therefore 
has to either check it off or allow it to remain unanswered, caus- 
ing the company to return the report to him for correction and 
this in turn requiring him to make another trip to the claimant 
if he is conscientious and gives the company the information they 
desire. When a blank has not been furnished by the company, 
then it is necessary that the physician make his examination and 
report his findings in his own way. It is very important that he 
obtains the claimant's name, address, age, occupation, weight, 
height, date of accident, place of accident and mode of occurrence, 
with the signs and symptoms together with the length of house 
confinement and the duration of total and partial disability. After 
securing the history as above, it is necessary that an examination 
be made of that part of the body which has been injured. When 
an individual is suft'ering from a sprain, contusion or abrasion, 
and these injuries are covered by dressings, they are very easily 
removed and an examination made. If the injury be more severe, 
such as a fracture or dislocation, the dressings should not be re 
moved unless in the presence of the attending physician. If they 
are removed under such circumstances and any ill result super- 
venes, it is always said to be the fault of the examining surgeon, 
and the company may possibly be held liable for any damages 
which the claimant might wash to make. If a fracture or disloca- 
tion be claimed, and it is the opinion of the examining surgeon 
that such is not the case and that the claim is a fraudulent one, 
then it is best that the examiner remove the dressings and know 
if the condition as claimed exists or not. Sometimes such injuries 
as sprains, or fracture of the ribs are treated by having the parts 
covered by adhesive plaster. In these cases the examining physi- 
cian must be guided as above indicated as to whether he removes 
the plaster or not. AVhen lacerated or incised wounds exist on 
an}^ part of the body and are covered by dressings, the examining 
surgeon can easily ascertain if such wounds exist by removing the 
outside bandage and then lifting up a corner of the dressing, being 
very careful not to touch the parts or the gauze which comes in 
contact with the open wound. If careful attention is paid to this 
part, the examiner knows he has not caused any infection, should 
the same show itself at a later date and he be accused of producing 
it by removing the dressings. The examiner will meet a number 
of conditions which have not been enumerated above, and to 
meet them he must use his own best judgment and common sense. 



COMPANY REQUIREMENTS 27 

COMPANY REQUIREMENTS: Insurance companies de- 
sire a report on an individual who has been injured, for the pur- 
pose of furnishing them with information which may be used in 
the equitable settlement of the case; and if a physician will bear 
in mind the important parts of a report as given under the above 
headings, he will be able to send in a report to his company that 
will meet all of its requirements and thus enable it to settle the 
case fairly to all concerned. In addition to securing the desired 
information, it is absolutely necessary that the examination be 
made promptly and the report forwarded to the company just 
as soon as possible. If an individual suffers from an injury to any 
part of the body, the examiner should state the exact location; 
w^hen a contusion, the area of tissue involved must be given, if an 
incised or lacerated wound, the length, together with the number 
of sutures required to close it. This enables the medical director 
to judge as to the duration of disability which will or has ensued. 

MEDICAL TERMS: All accident insurance companies 
employ an individual whose duty it is to look over the various 
claims received and who is called a claim examiner. The occu- 
pant of this position is one who has had experience in adjusting 
accident and health claims, but he is seldom a graduate in medi- 
cine; therefore, when sending in a report to an accident insurance 
company, it is necessary that the physician use terms and expres- 
sions w^hich may be understood by laymen. The examiner may 
use medical terms if he wishes, but in every case they should be 
explained. A claim examiner is more or less familiar with medical 
phraseology and in a number of cases is not compelled to look up 
the meaning of medical words; but in others, unless the explana- 
tion is given with the report, he loses valuable time in searching 
for the definition of a term used by the examiner. 

If physicians who examine for insurance companies will bear 
this in mind .and always make their reports intelligible to one who 
is not familiar with medical terms, the report will be more credit- 
able to the examiner and he will stand in better favor with the 
individual who has to read them. 

NO PRESCRIBING BY EXAMINER: Physicians are 
often asked to prescribe or suggest other forms of treatment for 
the injured party; imder no circumstances should the examining 
physician give such advice. If he does so, he immediately causes 
trouble between the attending physician and his patient, and tin's 
trouble extends and involves himself with his brother physician. 



28 ACCIDENT EXAMINATIONS 

If for any reason the treatment does not meet with his approval, 
it is his duty as the representative of the company to confer with 
the attending physician, and, if possible, point out to him where 
he is in error and have the proper treatment given to the claimant. 

NO CRITICISM OF ATTENDING PHYSICIAN : Claim- 
ants will often ask the examiner of an insurance company if they 
are getting the proper treatment, and sometimes will state openly 
that they know they are not. This may or may not be true, but 
whether it is or is not, the examining surgeon for the insurance 
company should be exceedingly careful that he does not say a 
single word against his professional confere even though he knows 
that the treatment is not proper and is not satisfactory to the 
claimant, it is not his duty to agree with the claimant and censure 
the attending physician in any way or manner whatsoever. If 
he mentally agrees with the claimant, he should not indicate to 
him in any manner that he does so, but he should follow the lines 
as laid out under the above heading and confer with the attend- 
ing physician at a time when the claimant is not present. Pro- 
fessional courtesy demands this, and in addition the examiner is 
sure to make a friend out of the attending physician and also the 
claimant, when he refuses to be led into expressing an adverse 
opinion concerning another doctor. 

DIAGNOSIS AND PROGNOSIS: An insurance examiner 
is often asked by one suffering from an accident if the diagnosis, 
as given by the attending physician, is correct. In such cases, if 
it is correct, it is well to say so and uphold the attending physi- 
cian in every way possible; should it not be correct, an evasive 
answer can easily be given and the attending physician consulted 
at a later date. The prognosis as given by the attending physi- 
cian should not be commented upon by the examiner even though 
he is asked to express an opinion by the claimant, except in cases 
where he intends or hopes to make an adjustment of the case. 
When the examiner has the authority to settle the case, he may 
himself ask for the prognosis of the attending physician, for the 
better purpose of guiding his own judgment in making a settle- 
ment. If the prognosis is acceptable to himself, and he can effect 
a settlement according to it, it is best that he do so without ex- 
pressing his own opinion unless it be to confirm that of the at- 
tending physician. 

REMARKS : Physicians who examine for insurance com- 
panies are expected to furnish the company with any information 



ACCIDENT EXAMINATION BLANK 29 

that may come into their possession regarding a certain case, and 
for this purpose blanks usually contain space under this heading. 
Sometimes, however, a doctor does not care to put down on his 
examination blank, and especially when that blank is first pre- 
sented to the agent, some information that he may have secured 
and which is not specifically demanded by the blank. Under such 
circumstances, it is his duty to send the company this information 
in a confidential communication. 

BLANK: If a company in asking for an examination of an 
individual has not furnished a blank form, the examiner may use 
the following which will usually furnish all the information that 
iany company would desire. 



Policy No Claim No. 

ACCIDENT EXAMINATION BLANK 



Is[ame jResidence and 

(Place of Examination 

Date of Examination 190 M. Occupation 

Previous Occupation 

Present weight lbs. Age years. 

Weight lbs years ago. 

Height feet inches. Appearance Nationality 

History of previous accidents, diseases or operations 



Date of Accident 190 .... M. Place of Accident 

Mode of Occurrence 



Signs . . . . 
Symptoms 



Abrasion . 
Laceration 
Contusion 



Location ,. . . 

Incision 

and 
Extent of Sprain 

Dislocation 

Fracture 

Burn or Scald 

Punctured Wound 

Confined to the house from 190 .... M. to 190 .... M. 

Totally Disabled from 190 .... M. to 190 .... M. 



30 HEALTH EXAMINATIONS 



Partially Disabled from 190 

Accident Insurance Carried 



Attended by Dr Address 

From 190 to 190 

Prognosis 

Remarks 



The above form of accident blank is one that has been used 
by the author and found very satisfactory in reporting cases to 
different insurance companies, and as it appears plain and easily 
understood by any one, it is not considered necessary to make 
any explanations concerning any part of it, as the blank explains 
itself. 



PART II 

HEALTH EXAMINATIONS 

x\ccident insurance companies issue a form of insurance 
known as a health or sickness policy, and this provides weekly in- 
demnity to an individual who is suffering from a disease which is 
covered by the policy. Some policies are known as special health 
policies and cover only a limited number of diseases, these dis- 
eases being enumerated in the body of the contract. A general 
health policy covers disability from all diseases, subject of course 
to the conditions of the policy. When an individual who is carry- 
ing either one of these forms of policies becomes ill, it is his duty 
to notify the insurance company which in turn notifies its examin- 
ing physician and requests that an examination be made and a. 
report furnished them. It is considered very important by aa 
insurance company that its own physician make an examination 
of the party who is ill for the reason that in the special health 
forms, it is necessary that a man be suffering f.rom one of the dis- . 
eases mentioned in the policy in order that he may be covered by f 
it and entitled to weekly indemnity. The examination and report 
of an individual who is carrying a health policy, while on the same 
lines as one who is carrying an accident form, differs from it in 
many ways. 



PURPOSE OF EXAMINATION 31 

PURPOSE OF EXAMINATION : It is extremely important 
for an insurance company to know the exact cause of disability 
of any of its policy-holders and especially when the policy-holder 
is covered by a limited or special health form. This can be read- 
ily understood when it is recalled that if typhoid fever is covered 
by one of these limited forms and the individual is suffering from 
another disease which is not covered by the policy, it is highly 
important that the company know the proper diagnosis in the 
case. If it is not so informed, it may pay out one or more weeks 
of indemnity for sickness which should not be payable under the 
conditions of the policy. Physicians who are examining cases 
in which indemnity is claimed under a health policy, must be ex- 
ceedingly careful to make a proper diagnosis of the case, as any 
mistake on their part may cost the company considerable money. 

PLACE OF EXAMINATION : Health policies usually re- 
quire house confinement as one of the conditions under which 
indemnity is payable, and when an individual makes a claim on 
a company for indemnity, it is supposed that he is confined to the 
house; therefore, the examination must be made at his residence 
or hospital, if he has been removed to such a place. 

EXAMINATION WITHOUT ATTENDING PHYSI- 
CIAN : As in the case of an accident insurance policy, the ex- 
aminer of the insurance company has the right to make an 
examination of the policy-holder without conferring with the at- 
tending physician. He can use his own pleasure as to whether 
he consults with the attending physician before making an ex- 
amination. If he does make an appointment, he will of course 
have no difficulty in examining the claimant. Should he call on 
the policy-holder and be denied admission to the patient, he can 
generally see him by stating to the family that he is a physician 
himself and under the terms of the policy, he has the right "to 
see and examine the claimant as often as he deems necessary." 
If the individual is very ill, an examining physician would in most 
cases only go into the room and remain a few minutes, simply 
satisfying himself that the person is in such a condition. 

EXAMINATION WITH ATTENDING PHYSICIAN: 
Should the company on receiving notification that one of its 
policy-holders is sufifering from an illness be asked at the same 
time that its examiner make an appointment with the attending 
physician for an examination, it is best to comply with the re- 
quest, and either call the attending physician 1)y telephone or 



32 HEALTH EXAMINATIONS 

write him and arrange an appointment at an early date. If the 
company or the examiner has any suspicion that the individual 
is intending to make a fraudulent claim, an examination of the 
party should be made at once without regard to the request that 
the attending physician be present. In such cases when the ex- 
aminer calls on the person who is said to be ill, he may be denied 
permission to see him or make an examination; when it is his 
duty to state to the person in authority, that he is a physician of 
the company and has called to make an examination and that he 
has the right to do so under the terms of the pohcy. If permis- 
sion is still refused, he should state the company reserves the 
right to stand on that condition of the policy, which makes it void 
if permission is refused to any of its medical examiners to make 
an examination whenever they consider it necessary. When these 
explanations are given to the family or to the one who is refusing 
permission to see the claimant, the doctor generally succeeds in 
making the examination as he desires. 

EXAMINATION of an individual sufifering from an illness 
and carrying a health or sickness policy, should be made immedi- 
ately upon receipt of request from the company. If a blank has 
been furnished, it is of course necessary that the questions be 
asked and the answers filled in. Sometimes it is more convenient 
to the examining physician to only ask part of the questions and 
then make the physical examination and form his opinion as to 
the cause of illness. In such cases it is always well to look over 
the blank before leaving the house and notice if any information 
is demanded which has not yet been acquired by the physician. 
Should the company not send a blank and the examiner be com- 
pelled to rely on his own judgment and experience, he should take 
the name and address of the party, occupation, previous occupa- 
tion, present weight, also the weight some months previously if 
there has been any change, the height, age, appearance and nation- 
ality. After this part has been learned a history of previous acci- 
dents or illnesses should be secured and if any are noted, the com- 
pany wants the date, duration, cause and condition of recovery of 
each one. After having secured this, the date of sickness should be 
taken, with its mode of onset, together with the signs and symp- 
toms, after which the temperature and pulse may be ascertained. 
It is also necessary to give the dates between which house con- 
finement existed and the length of total disability; and when total 
disability is existing after the termination of house confinement 



COMPANY REQUIREMENTS 33 

the company wants to know how long it has lasted. Having 
secured this part, a good examiner will then proceed to make a 
physical examination of the individual, paying special attention to 
that part of the body which is involved in the present illness, and 
after he has finished that part, the heart and lungs should always 
be examined, and if any abnormality is found, it should be re- 
ported immediately so that the company may cancel the policy 
after the termination of the illness, if it considers that action 
necessary. To make an examination as described would seem to 
require considerable time, but if the examiner has a routine to 
follow, he can very easily secure answers to his questions and then 
the physical examination which tells him the cause of the illness 
can be just as easily and quickly done, and when he has finished 
he feels confident that he has not overlooked anything that may 
be of value to the company; in other words, he has used system 
in his examination and the result is a completed report which 
should be forwarded to the home office at once. 

COMPANY REQUIREMENTS: When making an exam- 
ination under a health policy, the company must be furnished 
with certain information in order that it may take intelligent ac- 
tion on the case. Each and every question on the blank should 
be answered in a brief manner, but not so concisely that important 
information is omitted. It is often necessary to add information 
that is not demanded by the company, which is important and 
which will assist the medical director in deciding as to the merits 
of the case. In addition to the above, the company demands that 
no delay in making the examination occur after the request 
reaches the hands of the examiner, and that the report be mailed 
promptly. In giving the signs and symptoms and the reason for 
making the diagnosis, it is necessary that all signs and symptoms 
be described briefly so that the medical director may not only 
know himself, but may also be able to show at a later date that 
such a disease existed, and this can only be done when the ex- 
aminer puts down on his report a full, yet concise summary of his 
examination. 

NO PRESCRIBING: A physician is asked more often to 
prescribe when he makes an examination of an individual who is 
sick, than when he sees an accident case, and it hardly seems 
necessary to caution any one that such a thing should not be done, 
but when seeing a number of cases, and especially some who are 
nervous and are very persistent in asking for advice, it will be 



34 HEALTH EXAMINATIONS 

found hard to refuse such information. It must be done, how- 
ever, but in such a courteous manner that no offence will be 
given to the claimant. 

NO CRITICISM OF ATTENDING PHYSICIAN: In 
cases where the diagnosis is doubtful there is a tendency on the 
part of the examining physician to state that he does not believe 
the individual is suffering from a disease as claimed. While this 
is not exactly in the shape of criticism, yet it can readily be con- 
strued as such by the attending physician; therefore, when the ex- 
aminer does not agree w4th the physician of the patient, it is best 
to remain silent in the presence of the claimant, and if necessary, 
at a later time, confer with the attending physician by telephone 
or otherwise. When the individual carries a limited health form 
and the diagnosis by the attending physician is correct and the 
disease is not covered by the policy, the examiner is within his 
rights in stating to the claimant that he is suffering with the dis- 
ease as diagnosed by his attending physician, but such a disease 
does not entitle him to indemnity under the terms of his contract 
with the company. It will be seen in a case of this kind that the 
examiner is not criticising the attending physician, but is agreeing 
with him and at the same time he is protecting the interests of 
the company by keeping the individual from making a claim. If 
that party knows in advance that he is not covered by his policy, 
he will accept his position gracefully, yet if he does not know and 
makes a claim and the claim is disallowed, he is angry with the 
company and is ready to say his insurance is no good and many 
other untrue things. If the diagnosis as made by the attending 
physician and the examiner is not the same, but the two diseases 
are closely allied to each other and one is covered by the policy, 
while the other is not, it is just as well that the examiner does not 
express his opinion. For example, if an individual is suffering 
from the grippe and in addition has acute bronchitis, and this lat- 
ter disease only is covered, the attending physician can certify to 
the insurance company for the benefit of his patient that he is 
suffering from bronchitis. This statement may be correct, al- 
though the bronchitis is only a complication, the real disease being 
the grippe. When the examining physician sees the individual, 
he recognizes the fact that the party is suffering from the grippe, 
which is complicated by bronchitis. It is useless to make any 
statement to the claimant that he is suffering from anything ex- 
cept bronchitis, as the attending physician will stick to the fact 



HEALTH EXAMINATION BLANK 



35 



that the man has bronchitis and the company must pay the claim, 
therefore it is advisable that the examiner in such cases report the 
condition to the company only and not express any opinion to 
the claimant or the attending physician. By doing so the ex- 
aminer will avoid being accused of criticising a brother physician. 
BLANK : It is always best in reporting the results of a health 
examination that it be done on a blank form which is furnished 
by the company. If this form has not been forwarded with the 
request for the examination, an examiner can make out his report 
according to the following blank, which has been found from 
experience to answer the purpose of most companies, giving them 
the information desired. 



Policy No. 



Claim No. 



HEALTH EXAMINATION BLANK. 



Name 

Date of Examination 



190 



j Residence and 

Ipiace of Examination . . 

Occupation 

Previous Occupation 

Present Weight lbs. Height feet 

Weight lbs months ago. Age years. 

Appearance Nationality 



inches. 



History of Previous Illnesses, Accidents or Operations 



Date of Sickness 
Mode of Onset . . 



190 



M. 



Symptoms 



Signs of Disease 



Temperature Pulse . . . . , Its Character 

(When taken) 

Diagnosis 

House Confinement from 190 .... M. to 190 .... M. 

Totally Disabled from 190 .... M. to 190 .... M. 

Convalescent but totally disabled with- 
out house confinement from 190 .... M. to 100 .... M. 

Health Insurance carried in Company. S per week. 

Attended by Dr Address from 190 . . 

to 190 . . 

If disability is prolonged, cause 

Prognosis 

Claimant regarded as risk for health insurance. 

Remarks 



36 HEALTH EXAMINATIONS 

It seems hardly necessary to add any explanation to the above 
form, but it might be well to again state that an insurance com- 
pany expects the report to reach them promptly and with each 
question answered. Blanks that are held for a number of days 
after having been filled .in, even though the examination has been 
made promptly, are of Httle service to the company; the same also 
applies when the questions are unanswered and no explanation 
given. 

DIAGNOSIS : An examiner must be capable of making a 
diagnosis at the first visit in practically every case which he ex- 
amines for an insurance company that is covered by a health 
policy. When the diagnosis has been made by the examining 
physician, it is not necessary that his findings be communicated 
to the claimant, except when the diagnosis is the same as that 
given by the attending physician, in which case it is always well 
to say that the diagnosis is correct. If the examiner does not 
agree with the attending physician and makes a different diagnosis 
of the illness, it is best that he does not give the claimant the 
benefit of his opinion, but he should send it to the company with 
his reasons for differing with the attending physician. 

PROGNOSIS : Almost every person who is ill is desirous of 
knowing the time when the sickness will probably terminate, and 
the question as to the prognosis of the disease is asked of the 
examiner in almost every case. When thus questioned by the 
claimant, an examiner will save himself considerable trouble and 
annoyance if he will ascertain the prognosis of the attending phy- 
sician and then confirm that, unless he thinks the time is entirely 
too long when he may say that in his opinion the individual will 
have recovered, unless complications arise, in a time somewhat 
shorter than that given by the attending physician. By giving 
such a prognosis he causes no annoyance to the attending phy- 
sician and in addition he probably helps the claimant to recover 
more quickly, as every sick one is made better by good news of 
any kind. 

REMARKS : All health blanks contain a space which is 
allotted for remarks by the examiner, and this space should be 
used to convey any information to the company which has been 
learned at the examination and has not been put down on the 
blank at some other part. If an examiner is reporting the result 
of his examination by letter, he is supposed to put all of his in- 
formation in a concise and readable form, taking up the different 



LIABILITY EXAMINATIONS 37 

parts of the case from the beginning to the end and giving the 
medical director or claim examiner such a good idea of the case 
that he can almost imagine seeing it himself. 



PART III 

LIABILITY EXAMINATIONS 

Examination of individuals who are not covered by an accident 
or health poHcy, but who are injured as the result of negligence 
on the part of the company or its employees, is the most difficult 
examination that can be made by a physician for an insurance 
company or other corporation. In these cases the injured party 
belongs to a class known as "Public;" in other words, he is not 
covered by an insurance policy, but the person or the company 
who injures him does carry a policy exempting them from all lia- 
bility for any injuries that may be sustained by any one outside of 
their employ. It can thus be seen that individuals injured under 
these conditions may have right of action against the corporation 
to whose neghgence they were injured and thus secure a verdict 
against the corporation or the insurance company which has in- 
sured the corporation against such liability. When an examina- 
tion is asked by a company of an individual so injured, there are a 
number of points that must be remembered and inquired into, 
as it is impossible to know at the time of the examination if the 
case will be settled amicably or will reach a court trial. If the 
latter, a physician must be prepared to be called upon by the 
insurance company or corporation and be able to testify from 
original notes that were taken at the time of the examination, it 
being impossible to remember the details of the examination when 
the case does not reach a court trial until two to five years or 
more have passed. Any notes that are made, even if on a slip of 
paper, must be retained, and as they are original they can be used 
as evidence by the compan}^ if needed. In these examinations 
it must be remembered the person who wishes the information 
for the company is the adjuster and not the medical director: 
therefore, in order that the report may be of ready use, it nuist 
be readable to a la3anan. The examiner may use technical tonus 
if he wishes, but he must thoroughly explain them. An adjuster 



38 LIABILITY EXAMINATIONS 

is constantly on the alert to detect claims in which no liability 
exists, and nothing is more exasperating for him than to have to 
search among papers and books for the definition of medical terms 
which have been used and which might have been avoided if the 
examiner knew differently. 

PERMISSION TO MAKE EXAMINATION: It must be 
remembered in liabiHty accidents that the examiner of the insur- 
ance company or corporation has no right to make an examina- 
tion of the individual unless permission has been secured from 
him, the attending physician or from the attorney, if the case has 
reached the hands of such a party. This duty of securing per- 
mission does not often depend on the efforts of the examining 
surgeon, as the company usually makes the necessary arrange- 
ments with the injured party or the attorney, and the examiner 
is asked to confer with the attending physician and make an ap- 
pointment for the examination. These examinations are some- 
times refused by the claimant and also by the attorney, in which 
case the insurance company or corporation is compelled to wait 
until the case reaches a court trial, at which time, at the request 
of the company the judge will order the claimant to be examined 
by a reputable physician who is chosen by the company for this 
purpose. When the case is tried in a Federal Court, it is not pos- 
sible to secure this examination if the attorney objects to it and 
when secured is only done so through his courtesy. 

THE PURPOSE OF THE EXAMINATION depends on 
the time it is requested. When the company desires an examina- 
tion shortly after the injury has been sustained, it has in view 
the object of knowing exactly the extent of the injuries at that 
time and a proper prognosis from the examiner after he has seen 
and carefully examined the individual. If the examination is re- 
quested some months or years after the accident occurred, the 
company desires to know the results of the examination at the 
time it is made, the extent and situation of any existing scars, loss 
of motion or any impairment of function that has resulted from 
the injury or in other words it wants to knoAv if there is any per- 
manent disability or deformity existing at the time of the exami- 
nation, and if so, the examiner must give a full and complete de- 
scription of the disability or deformity as he finds existing. If 
he thinks the disability is exaggerated, he should not fail to trans- 
mit his opinion to the company. If he believes it is fraudulent, he 
should endeavor to find evidence of such fraud, and when called 



PLACE OF EXAMINATION 39 

upon in court, be able to show and convince a jury that the fraud 
exists and the disabihty as claimed is not really present. Indi- 
viduals injured under these conditions can claim damages from 
an insurance company or corporation, — provided the company is 
liable, — for permanent deformity, such as , permanent scars, cuts 
or burns, mal-union of any bones that may have been fractured 
or the impairment of any function which may appear permanent. 

PLACE OF EXAMINATION : When the individual is to 
be examined shortly after the accident occurred, the examination 
can usually be made at the home or hospital, if the person is con- 
fined indoors. When the party is able to get around, it is often 
necessary that the examiner make the appointment for the ex- 
amination at the office of the attending physician and frequently 
when the case is in the hands of an attorney, he requests that the 
examination be held at his office in order that he may be present, 
as he thinks he must protect his client in every way. Sometimes 
it is more convenient that the examination be made at the ofifice 
of the examining surgeon of the company, in which case the at- 
tending physician will usually consent to be present at the ofifice 
of his professional brother. It is very seldom that an examina- 
tion can be made at the ofifice of the examining surgeon without 
the attendance of either the doctor or the attorney of the case. 
When this can be done, it simplifiies the arrangement for the ex- 
amination, but does not make it any the less important that it be 
properly and thoroughly made. 

RELATIONS OF EXAMINER: A physician who exam- 
ines for an insurance company is employed by them for the pur- 
pose of making an examination and submitting a report of an in- 
dividual on which they may deem such an examination necessary 
and as a number of liability cases reach a court trial, it is necessary 
that the examiner make the most thorough examination that he is 
capable of making and in addition refrain from giving the claimant, 
the attending physician or the attorney of the opposite side, the 
benefit of his examination or opinion. Bearing the point in mind 
that he may be called upon at a later date to testify as to the find- 
ings of his examination, he must take notes at the time he makes 
the examination and keep these original notes for use at a future 
date if his presence is required in court. The examiner of tlie 
company must remember that he is examining the claimant 
through the courtesy of some one, either the injured jxirty or the 
attorney. This must not prevent him, however, from making a 



40 LIABILITY EXAMINATIONS 

thorough examination or at least in attempting to do so, and if 
refused permission to make an examination of any part he deems 
necessary, he should make a note of such refusal. If the claimant 
refuses to answer questions which have a bearing on his injury 
or disability, the doctor should also report these facts. The ex- 
aminer should be most courteous in his manner and use all the 
tact and diplomacy he can command, as by so doing he can gene- 
rally secure answers to any questions he may ask. Very often 
the claimant will refuse to answer a question and a few minutes 
later will answer the same question if put in another manner and 
during another part of the examination; therefore, while making 
note of the fact that certain questions have been refused, the ex- 
aminer should also ask them again and if possible secure an- 
swers. 

When the attending physician is present at the examination, 
he will sometimes assist the examiner in every way he can, not 
only answering questions, but also giving a history of the case as 
he knows it; other times, the attending physician will simply say, 
"there is your party, examine him." When the attending physi- 
cian is courteous and assists the examiner, he also assists his 
patient, as any physician who is examining for an insurance com- 
pany is capable of getting the desired information, whether he has 
the assistance of the attending physician or not. The attending 
physician at the beginning of the examination may be inclined 
to refuse assistance to the examiner, but if he is handled with care 
and in a diplomatic manner, he will usually furnish the desired in- 
formation before the examination is finished. Just as soon as the 
attending physician attempts to hinder the examiner in any way 
by refusing assistance, just so soon is the examiner put on his 
guard, and not only his ability but his professional honor is at 
stake, and he is sure to get the information desired. He may have 
to get it after the examination is over and from another physician 
who has heard of the case in a round-about way. Information 
thus secured, of course, cannot be used in court, but it can often 
be used by the insurance company and be of much service to them. 

If the examination is held in the presence of the attorney 
for the opposite party, it is his intention in most cases to be there 
for the purpose as he believes, of preventing his client giving any 
information to the examiner that may be of use to the company. 
He will therefore in many cases instruct his client not to answer 
certain questions of the examiner, and while he has the right and 



LIABILITY EXAMINATION BLANK 41 

power to have him refuse to answer all questions, such a condition 
would hardly occur; if it did the examiner could use his own judg- 
ment as to continuing the examination or not. Should the ex- 
aminer refuse to make the examination under such conditions 
and wait until the case reaches a court trial, he will often be able 
to obtain more information for his company, provided the in- 
juries are permanent. In cases where the injuries are only tem- 
porary, the examiner should use all the good judgment and tact 
that he can command and make the best examination possible 
under the circumstances. Attorneys when present at the exami- 
nation will generally instruct their client not to answer any ques- 
tions concerning the accident or how it occurred. While this part 
is not absolutely necessary for the physician, it is always well that 
he give the claimant's statement as to how the injuries were re- 
ceived. When a claimant, by the instruction of his attorney, re- 
fuses to tell how the accident happened, it is for the purpose of 
denying the company any information that may help to show if 
they are liable for the accident. An attorney will seldom refuse 
to permit his client to answer questions concerning his physical 
condition previous to the accident, and also tell the history of 
the case after the accident occurred up to the time of the examina- 
tion. Neither will he very often refuse to allow a physical ex- 
amination of the parts injured or liable to be concerned in the 
injury. This applies to women as well as to men. 

BLANK: A satisfactory examination of a liability case can- 
not be made without the use of a blank especially designed for that 
purpose, or the use of a skeleton key which permits the examiner 
to secure all the information that is necessary. As there are so 
many little points in liability examinations that may be over- 
looked, it is absolutely necessary in such cases that the examiner 
use a blank, or a form which takes the place of it. On account of 
the importance of many parts of a liability examination report, the 
following blank is given and each part is taken up and explained 
in detail : 



¥ 



Policy Form Claim No. 

LIABILITY EXAMINATION BLANK. 



jsja^g Residence and 

Place of Examination 

Date of Examination 190 . . . . M. Age years. Height Ft In. 

Appearance Nationality 



42 LIABILITY EXAMINATIONS 

Weight pounds. Weight pounds before accident. 

Occupation Previous Occupations and where employed 



Enaployed by . address at time of accident. 

Nearest Relative's name address occupation 

Supports ^. 

(Names and Addresses) 
Persons present at examination with address 



History of previous illnesses 



History of Previous Accidents 
History of Surgical Operations 
Statement of Injured Party . . 



Names of Attending Physicians Address 

Examination of Claimant: 

Head 

Chest 

Abdomen ■ 

Back 5. 

Genital Organs ...._.. 

Upper Extremities 

Lower Extremities 

Kidneys 

Pulse 

Temperature 

Diagnosis 

Prognosis 

Remarks 



Name: It is important that the name of the injured party is 
correctly spelled and that his surname, also any initials, be given. 
, Residence and Place of Examination: If the examination is 
made at the residence of the injured party, his address is placed on 
the blank line following the above subject. Should the examina- 
tion not be made at his residence, the words "residence and" are 
crossed out, thus giving the place of the examination, and the 
residence of the individual must be given below under Remarks. 
Date of Examination: Even though the letter or report is 
dated, there should be stated in the body of the report the date 
of the examination, also the time of day it is made. 



EXPLANATION OF BLANK 43 

Age is one of the important answers of a liability insurance 
examination, as the length of time disabiHty will last depends to 
a certain extent on this, and especially when a claimant is past 
fifty years of age. 

Height: Unless the examiner can estimate the height of an 
individual correctly, he should measure him. 

Appearance: It is always well to state the appearance of the 
person examined, whether fat or flabby, thin and anemic, robust, 
weak or other conditions which impress the examiner. 

Weight: It is not often that the claimant can be weighed, but 
nearly the exact weight can be secured by asking how much it is, 
and then the examiner by using his own judgment as to the truth- 
fulness of the reply, can estimate closely the correct figure. If 
there is a history of any loss of weight, it is important that the 
company know how much the party weighed before the accident 
occurred and also the cause of the loss. 

Nationality should alw^ays be given, as the adjuster is often 
furnished additional information by this one point alone. 

Occupation at the time the accident was sustained must not be 
omitted, together with previous occupations, unless there has 
been a number of changes, in which case occupations covering the 
previous five years should be noted with the length of time spent 
in each. 

Nearest Relative's Name: If the injured part}^ is a married 
man, the name of his wife, her occupation and also the residence 
should be given. This latter is important, because the man may 
not be living with his wife or supporting her. Should the claim- 
ant be a young unmarried person, it is very important that the 
nearest relative's name be secured and this is especially true when 
the claimant is not yet of age. In such a case the parents have 
the right to claim damages for the minor and also for themselves. 
If either of the parents are living, the name of the father, if alive, 
should be given; if not the mother's name, and in either case the 
address and occupation. Should the parents be dead, the name, 
residence and occupation of the nearest living relative must be 
secured. 

Persons Present: Under this heading the name of any person 
who is present at the examination, either a part or all the time, 
should be given, also the residence. This may become very im- 
portant at a later date if the case reaches a court trial. 

History of Previous Ilhicsses should be secured in every case. 



44 LIABILITY EXAMINATIONS 

If the sickness has been severe enough to cause disability of a 
week or more and has occurred within the last ten years, it is 
necessary to give the date of the disability, the cause, duration, 
condition of recovery and the name and address of the attending 
physician. 

History of Previous Accidents: If an accident has been suf- 
fered at any time since childhood and has left any permanent de- 
formity or disability, the date of the accident should be given, how 
it occurred, and a description of the parts injured. This descrip- 
tion should show exactly any deformity or disability that existed 
previous to the accident for which the examination is being made. 
The duration of disability is necessary, as is also the name and 
address of the attending physician. If a previous accident has 
not caused any present disability or deformity, it is sufficient to 
state the date of this accident, the parts involved and the condi- 
tion of recovery. 

Statement of Injured Party: The claimant should be asked to 
state in his own words exactly how the accident was sustained, 
first giving the date and hour of the day, the place and exact 
mode of occurrence. After this is given, the person should state 
what was done immediately following the accident; if taken to a 
hospital or other place, the manner of conveyance, how long* 
confinement was necessary in the hospital or residence, together 
with the length of time in bed. If the individual was unconscious 
as a result of the accident, the above information can easily be 
secured from him, as he has probably been told by some one what 
was done with him immediately following the accident. After 
securing this information, the examiner should ascertain how long 
disability lasted after house confinement ended. The date when 
the party returned to work and the name and address of the at- 
tending ph3^sician. A claimant must always be asked if he has 
had one or more attending physicians, as oftentimes in these 
cases there is an attempt at fraud and the name and address of 
one of the doctors is withheld. Such a report is of more value 
if the examiner will state how often the claimant has been seen 
by the attending physician and the places. 

Examination of Claimant: After the history has been taken, 
the examiner must carefully exafiiine the claimant, first paying 
particular attention to that part of the body which has been in- 
jured in the accident, noting any signs of the injury that exist at 
that time, any deformity that may be present or any abnormality 



NO PRESCRIBING BY EXAMINER 45 

of the part. After making an examination of this portion of the 
body, it is necessary in Habihty cases that the whole body be ex- 
amined, beginning at the head and going down. This part of the 
examination will show any evidence of injury of the head, face, 
ears, eyes, nose, mouth, throat, chest, abdomen, back, genital 
organs and the upper and lower extremities. After this part of 
the physical examination has been made, it is necessary in a num- 
ber of cases to take the temperature and pulse rate and inquire 
as to the condition of the kidneys, together with the state of appe- 
tite, digestion, ability to sleep and recuperate from fatigue and 
any other information which may be deemed necessary by the ex- 
aminer. 

Diagnosis: An insurance company always wants to know the 
diagnosis, and the examiner must be sure that he has made it 
correctly, and if necessary he should not hesitate to explain any 
part that he thinks might be obscure to the adjuster, always re- 
membering that the clearer he can get his reports the better satis- 
faction they will give. 

Prognosis is one of the most important parts of the report of 
a liability examination and should be as near correct as the ex- 
aminer can make it. There are some cases, however, in which it 
is impossible to give a prognosis with any degree of certainty, or 
unless qualified. The examiner, however, should make every 
effort to furnish this information to the company and should ap- 
proximate how long the disability will last in days, weeks or 
months, in addition to stating if there will be any permanent de- 
formity or disability as the result of the accident. 

Remarks: This heading is placed on every blank for the 
reason that it is almost impossible to design one that covers every 
case, and any information that may be secured which is not cov- 
ered by the different questions can be placed under this heading. 
It must be remembered by the examiner that the report of a lia- 
bility examination cannot contain too many details; if these details 
have any bearing on the case. 

NO PRESCRIBING BY EXAMINER: As stated under 
accident and health examinations, a physician examining a case 
for an insurance company should not under any circumstances 
prescribe, and this is especially important in a liability case for the 
reason that there is an attempt on the part of the claimant to hold 
the company liable for damages for an injury already sustained, 
and if the examiner allows himself to prescribe or even suggest a 



46 LIABILITY EXAMINATIONS 

certain line of treatment, the claimant has strengthened his case 
against the company or corporation. Individuals claiming 
damages from a company that is protected by a liability policy, do 
not often ask the examining surgeon of the company for any ad- 
vice, but may do so, and if they do, it should be refused. 

NO CRITICISM OF TREATMENT: The examining sur- 
geon should not criticise or venture an opinion as to the correct- 
ness of the treatment which is given to a person being examined 
under this form of policy. It is immaterial to the company 
whether the treatment is correct or not, for the reason that they 
may not be liable for damages, and even if they are, the opinion 
of the examiner for the company would not be accepted in the 
manner in which it was expressed. If the examiner should criti- 
cise the treatment of the attending physician, even though he 
had good grounds for such action, he would only comphcate the 
case further and make it that much harder for the adjuster to 
settle. These last two parts of an examination must always be 
remembered, no prescribing and no criticismi by the examiner of 
the company. 



CHAPTER IV 

POLICY FORMS 

PART I 

ACCIDENT POLICIES 

Insurance companies are permitted by their charters to as- 
sume the risk or Habihty in a number of different forms. There- 
fore, companies doing an accident, health or Uability business write 
accident or health insurance policies and also issue insurance to 
corporations which covers their liability against accidents to in- 
dividuals who are in no way connected with them. Accident in- 
surance policies as issued by the majority of companies are dated 
at twelve o'clock noon standard time and are in force for one 
month, three months, six months or one year from that date, 
ending at twelve o'clock noon, and are in effect immediately upon 
being issued and paid for by the purchaser. These policies pay 
indemnity for death or loss of time due to accidental injuries, 
when ''disability or death results directly and independently of all 
other causes, from bodily injuries effected solely through external, 
violent and accidental means." All insurance policies contain a 
number of conditions explicitly stating how much and under what 
phases weekly or death indemnity is payable, and these conditions 
are best described separately. 

ACCIDENTAL DEATH: "If such injuries alone result 
within ninety days from the date of accident in the death of the 

insured, the principal sum of $ shall be payable to the 

beneficiary named in copy of application endorsed hereon, if living, 
otherwise to the executors, administrators or assigns of the in- 
sured." It will thus be seen tliat if an individual carrying an acci- 
dent insurance policy meets with an accident whereby death oc- 
curs immediately or within ninety days, and is due entirely to the 

47 



48 ACCIDENT POLICIES 

effects of the accident, the insurance company will be liable for 
the amount stated in the policy; with, however, any exceptions or 
conditions that might be contained in the contract. 

LOSS OF TWO LIMBS OR EYES : "If such injuries alone 
result within ninety days from the date of accident in loss by re- 
moval of both hands at or above the wrists, or both feet at or 
above the ankles, or one hand and one foot at those places, or the 
irrecoverable loss of the entire sight of both eyes, the principal 
sum shall be payable to the insured in lieu of weekly indemnity as 
herein provided." Under this part of the contract, an insurance 
company considers an individual who has suffered any of these 
losses as practically unfit to follow any occupation, and therefore 
the full amount of the policy is payable to the claimant, and by 
such payment the company is released from all further liability 
and the policy cancelled. Some companies pay weekly indemnity 
from the date of accident to the date of dismemberment or loss 
of sight; provided this does not exceed ninety days. Therefore, 
such policies would pay weekly indemnity from the date of acci- 
dent to the date of operation if it was done under ninety days, and 
in addition would pay the face of the policy. 

LOSS OF ONE LIMB OR ONE EYE: "If such injuries 
alone result within ninety days from the date of accident in loss by 
removal of either hand at or above the wrist, or either foot at or 
above the ankle, or the irrecoverable loss of the entire sight of 

one eye, part of the principal sum shall be payable to 

the insured in lieu of weekly indemnity as herein provided." The 
amount payable for the loss of a hand or foot at or above the 
wrist or ankle varies, according to the company issuing the policy. 
Some companies pay the full amount of the policy, others one- 
half, one-third, one-fourth or one-fifth. Some insurance com- 
panies pay weekly indemnity for total disability from the date 
of accident to the date of operation for the removal of a hand or 
foot or the irrecoverable loss of one eye, if these contingencies 
arise under ninety days. This weekly indemnity is payable in ad- 
dition to the specified amount stated on the face of the policy. In 
any case when a company pays a specified amount for such a loss, 
the policy is cancelled and further accident insurance is usually 
denied the individual, as such a person is an impaired risk and 
is not capable of protecting himself in an emergency as well as 
one who has not suffered the loss of a hand or foot or one eye. ' 

INDEMNITY FOR TOTAL DISABILITY: "If such in- \ 



INDEMNITY FOR PARTIAL DISABILITY 49 

juries alone immediately, continuously and wholly disable the in- 
sured from prosecuting any and every kind of business pertaining 

to his occupation, the sum of $ per week shall be payable 

to the insured, as hereinafter provided, but not for more than two 
hundred consecutive weeks." All accident insurance policies con- 
tain a clause similar to the above, which explains itself. Total dis- 
ability as defined by an accident insurance poHcy is inability on 
the part of the individual to perform any part of the daily duties 
of his occupation. If a claimant whose duties require brain work 
in addition to other manual labor is confined to the house with a 
broken leg, such a person can dictate letters and direct his busi- 
ness by telephone and other means, but yet is considered totally 
disabled and paid weekly indemnity from the date of accident to 
the time he is able to return to his office and resume part of his 
work. 

INDEMNITY FOR PARTIAL DISABILITY: "If such in- 
juries shall not wholly disable the insured as above, but shall im- 
mediately, continuously and wholly disable him from the perform- 
ance of one or more important daily duties pertaining to his 
occupation, or if following a period of total disability resulting 
from such injuries, he shall be in like manner partially disabled 
(one-fifth, two-fifths, etc.) of the amount per week payable for 
total disabihty shall be payable to the insured for the period of 
such partial disability, but not for more than twenty-six consecu- 
tive weeks of partial disability." The amount payable for partial 
disability varies according to the company issuing the policy. 
Usually, however, a fixed sum of two-fifths of total disability is al- 
lowed for partial, but some companies, pay from one-fifth to four- 
fifths, one-third to two-thirds and one-fourth to three-fourths, ac- 
cording to the amount of disability present. In this clause of the 
contract it will be seen that partial disability is payable for injuries 
which cause a claimant to be unable to attend to all the duties of 
his business, whether totally disabled immediately after the acci- 
dent or not. If partial disability is not preceded by total, the limit 
of the company's liabihty is twenty-six weeks. Partial disability 
may also follow a period of total disability, provided this period 
of total does not run to the limit of the policy. If a period of total 
disability exists for twenty-six weeks less than the limit allowed 
for total and is followed by partial, this latter form may be allow od 
for the limit as provided in the policy. In other words, combined 
4 



50 ACCIDENT POLICIES 

total and partial disability cannot exceed the limit the policy pro- 
vides for total disability. 

COMBINATION BENEFITS: "If such injuries are sus- 
tained by means as aforesaid (i) while the insured is riding as a 
passenger and is in or upon any railway passenger car using 
steam, cable or electricity as a motive power, (2) or while a pas- 
senger on board a steam vessel Hcensed for the regular transpor- 
tation of passengers, (3) or while a passenger in an elevator pro- 
vided for passenger service, (4) or while in a burning building, the 
amount to be paid shall be double the sum specified in the section 
under which claim is m.ade." This clause of the policy makes in- 
surance companies liable for double the amount of weekly in- 
demnity in addition to double the specified amounts stated in the 
policy. 

ELECTIVE INDEMNITIES: "If the insured shall sustain 
an injury by means as aforesaid, which injury is named in the 
schedule of injuries hereinafter contained, he may elect, subject 
to all terms and conditions of the policy, to receive the amount of 
indemnity specified opposite such injury in lieu of all weekly in- 
demnity for either total or partial disability, provided he signifies 
his choice in writing addressed to the company at its home ofhce 
within .... days from the date of occurrence of said injury." All 
accident insurance policies do not contain the above clause, but 
when it is a part of the contract a claimant can secure an advance 
settlement of his claim within a short time after the accident 
occurs, provided he notifies the company within the time allowed 
by his policy, and this time is usually limited to from ten to fifteen 
days after the date of accident. If an accident occurs under any 
condition which doubles the indemnity payable and the claimant 
elects to accept a certain sum for his claim, he is paid double in- 
demnity as his policy states in the combination clause. 

FEES FOR SURGICAL OPERATIONS: "If such injuries 
sustained by the insured within the term of this polic}^, and the 
conditions thereof shall during a period of total or partial disability 
(as herein defined) resulting therefrom and within ninety days 
from the date of sustaining said injuries necessitate a surgical 
operation named in the schedule of operations hereinafter con- 
tained, the sum set opposite such operation in said schedule shall 
be pa3^able to the insured, provided, always, that such an amount 
shall not be payable for more than one operation as the result of 
injury or injuries sustained in any one accident. Operations not 



ACCUMULATIONS 51 

named in the schedule of operations are not covered." It will 
be seen from this part of an insurance contract, that if an indi- 
vidual sustains an accident and suffers total or partial disability, 
and within ninety da3^s from the date of injury an operation which 
is named under the schedule of operations is necessary, he is en- 
titled to weekly indemnity for total or partial disability, as the 
case may be, and in addition is paid the fixed sum for the opera- 
tion. If some part of the extremities of the body is amputated and 
the policy provides a specified sum for the loss of such a part, the 
claimant is entitled to this sum and in addition the amount stated 
in the schedule of operations for the operation necessary for the 
removal of the part. When the company pays weekly indemnity 
from the date of accident to the date of operation, the claimant 
would also be entitled to this in addition to the fixed sum for the 
loss of the part and the fixed sum for the operation. 

ACCUMULATIONS: "Each consecutive full year's re- 
newal of this polic}^, if paid annually in advance, shall add ten 
per cent, to the principal sum insured until such accumulations 
shall amount to fifty per cent, of said principal sum, and thereafter 
so long as this policy is maintained in force by annual premium 
payments the amount insured shall be the original principal sum 
plus the accumulations." The accumulation feature of an acci- 
dent policy was added within the last few years by practically all 
insurance companies for the purpose of preventing lapses and se- 
curing payment of the premium annually by making the policy 
more valuable to the insured the longer he carried it to within a 
certain limit, and when the premiums were paid annually in ad- 
vance. This accumulation applies to the principal sum only, and 
weekly indemnmity for total or partial disability is not increased 
by this clause. 

SPECIAL DEATH INDEMNITY: "If sun-stroke, freez- 
ing or hydrophobia accidentally suffered by the insured or the in- 
voluntary and unconscious inhalation of gas or other poisonous 
vapor shall result directly, independently and exclusively of all 
other causes in the death of the insured within ninety days from 
the date of exposure or infection, the company will pay the bene- 
ficiary herein named $ .." The amount of a special death 

benefit depends on the company issuing the policy: some com- 
panies paying the face of the contract and others only ixiying 
a stated portion of it, such as one-half, one-fifth, etc. Accident 
insurance policies do not pay weekly indemnity for disability when 



52 ACCIDENT POLICIES 

such disability results from any of the causes given under the 
above clause. 

CHANGE OF OCCUPATION : "If the insured is injured 
such disability results from any of the causes given under the 
the company as more hazardous than that stated in the policy, 
while doing work or performing duties belonging to any more 
hazardous occupation, the company's liability shall be only for 
such amounts as the premium paid by him will purchase at the 
rate fixed for such increased hazardousness." This clause in an 
accident poHcy is for the purpose of protecting the company 
against claimants who are insured under a classification which is 
not very liable to accidents and who change their occupation to 
one which is more hazardous. This is better explained by an ex- 
ample. If a physician who would be insured as a preferred risk 
should change his occupation and become a machinist, he would 
be more liable to accidental injuries. As a preferred risk he would 
be less Hable to accidents, and when they did occur the length of 
total disability w^ould be short and followed by partial disability; 
whereas as a machinst, there would be more chance of an acci- 
dent, and when such a claimant became injured, total disability 
would persist until the claimant could return to w^ork; in addition 
a preferred risk would pay less premium than an ordinary risk. It 
can thus be seen that a preferred risk changmg the occupation 
to one more hazardous should in justice to other policy-holders 
and the company, pay an increased premium. 

ADVANCED PAYMENTS: ''Claims for weekly indemnity 

of more than weeks or months duration shall be 

payable at the expiration of weeks or months total 

disability and at intervals of weeks or months 

thereafter; satisfactory affirmative proof of disability and its con- 
tinuance being furnished before each payment. Final proofs in 
all cases to be furnished as provided herein." This clause of an 
accident insurance policy is for the purpose of making partial pay- 
ments to a claimant during a period of continuous and prolonged 
total disability. Thus if an individual suffers from an accident, 
such as a head injury and total disability lasts a number of weeks 
or months, the majority of companies w^ill make partial payment 
of the claim at the end of a definite time; this time being fixed 
in the policy according to the company which issues it. Some 
companies make partial payments every eight weeks, others every 



NOTICE OP ACCIDENT 53 

ten, twelve, fourteen or sixteen weeks, this depending on the com- 
pany and the reading of the poHcy. 

NOTICE OF AN ACCIDENT: "Immediate notice in writ- 
ing of any accident and injury, fatal or non-fatal for which claim 
can be made shall be given to the company at its home office in 

, with full name and address of the insured, 

and unless satisfactory affirmative proof of death, loss of limb 
or sight, surgical operation or duration of disability is furnished 

in writing within days or weeks from the date 

of death, loss of limb or sight or surgical operation or termina- 
tion of disability, or in case of claim for the full limit, final claim 
is filed within days or weeks from the termina- 
tion of such Hmit, the company shall be released from all liability 
for the payment of any claim based thereon." This clause of an 
accident poHcy varies according to the company which issues it. 
Some insurance companies require immediate notice of the acci- 
dent and the courts have held that immediate notice is reasonable 
notice, other companies state a fixed time in the policy in which 
notice of accident must be given them. , An insurance company 
always looks with disfavor on a claim for accidental injuries when 
notice of injury has been received days or weeks after the occur- 
rence of the accident or the termination of disability, and seldom 
will it entertain a claim under such conditions. The company has 
no way of knowing through its agents or examiners of the exist- 
ence of an accident or disability as claimed by a claimant, and 
whenever such claims are received for total or partial disability, 
an investigation must be made and this requires a greater expense 
than if the company was informed at the time of the accident. 

IDENTIFICATION: "Upon receipt at the company's head 
office of the premium for the policy, the insured becomes entitled 
to the company's identification certificate, and if thereafter while 
the policy is in force and as the result of injuries covered thereby, 
is rendered physically unable to communicate with friends, the 
company will upon receipt of telegraphic or other information 
thereby transmit the same to relatives or friends and defray any 
necessary expense not exceeding Twenty Dollars for each One 
Thousand Dollars of insurance single indemnity, to place him or 
her in care of such friends." This is a clause that has been re- 
cently added to insurance policies, and while the company is will- 
ing to do as it says under this part of the contract, such a con- 
tingency seldom arises. 



54 ACCIDENT POLICIES 

BENEFICIARY INSURANCE: Accident insurance poli- 
cies as now written contain a number of special offers, and the 
beneficiary clause is not included in this, if the policy carries the 
accumulation feature. A policy-holder has the choice of accept- 
ing an accident policy which accumulates the longer he carries it 
or one in which the beneficiary is insured for certain accidents. 
This beneficiary clause varies in different companies, but the fol- 
lowing is a fair example: "In lieu of the ten per cent, addition- 
provided for in the policy, the following contract of insurance is 
issued on the person named as the beneficiary in the schedule of 
warranties herein contained. The said beneficiary is insured 
against disability or death resulting directly and independently of 
all other causes, from bodily injuries sustained through external, 
violent and accidental means, suicide, — sane or insane — not in- 
cluded, and received by the said beneficiary while a passenger in 
a passenger elevator; or in or on a railway conveyance propelled 
by steam, electricity, compressed air or cable and provided by a 
common carrier for passenger service; or in consequence of a 
burning building while said beneficiary is therein, in the following 
sums to wit: If said injuries received solely under the conditions 
set forth herein shall within ninety days from the date of accident 
result in any one of the following disabilities, the company will 
pay the amount set forth in the following schedule or a propor- 
tionate share thereof, as provided herein." Then follows a sched- 
ule in w^hich a fixed sum is allowed for certain losses, — amputa- 
tions, fractures and dislocations. It will be noticed that this bene- 
ficiary clause does not pay weekly indemnity to the beneficiary 
when injured, and in order that the beneficiary may receive in- 
demnit}^ for specified injuries, this person must be injured under 
conditions as set forth in the policy. 

CANCELLATION: "The company may cancel this policy 
by mailing copy of cancellation to the insured's residence address 
as given in application herefor, with its check for the unearned 
part, if any, of the premium.." All accident insurance policies con- 
tain this or a similar clause, for the purpose of terminating an 
accident policy which may be secured by fraudulent means or 
when the company decides for any other reason that it does not 
care to remain on the risk. This is an important condition of the 
policy from the standpoint of the company and is one which holds 
in courts of law. 

MEDICAL ATTENTION: All accident insurance policies 



MEDICAL EXAMINATION 55 

require the attendance of a registered and qualified physician 
during the period of disabiUty, and if this part of the poHcy is not 
compHed with, the company has the right to refuse the payment 
of indemnity. 

MEDICAL EXAMINATION: When an individual signs 
an application for an accident poHcy and accepts it, he gives the 
company the right to have any of its medical representatives make 
an examination of his person or body as often and whenever the 
company deems it necessary. This is an important clause from 
the standpoint of the examiner of the company, for the reason 
that the claimant has waived his rights of an examination, and 
therefore the examiner of the company can make the examination 
whenever he desires and without the presence of the attending 
physician. Medical ethics require courtesy among medical men, 
and the code of ethics should always be adhered to whenever pos- 
sible, but most physicians understand and expect that the medi- 
cal examiner of an insurance company will make an examination 
of their patient without their knowledge, as it would be almost 
impossible for an examiner of an insurance company to communi- 
cate each time with the attending physician and have him present 
when the examination is made. 

REMARKS : Accident insurance policies as issued by the 
large companies pay Five Dollars per week indemnity for each 
One Thousand Dollars of insurance carried by preferred risks. 
Thus if an individual carries Five Thousand Dollars of insurance 
against accidental death, he is entitled to Twenty-five Dollars per 
week for disability if injured in the usual ways; if injured under 
the doubling clause, the weekly indemnity would be Fifty Dollars 
per week. The cost of this insurance depends on the occupation 
of the policy-holder and is based on the hazard to accidents that 
exists. Preferred risks are charged Five Dollars per year for One 
Thousand Dollars of accidental death benefit, and in addition to 
this the weekly indemnity is also payable. Other risks pay from 
this rate, as high as Twenty or Twenty-five Dollars per One Thou- 
sand Dollars of death indemnity, the cost of this being based on 
the occupation of the insured. The premium on these policies is 
payable annually, semi-annually or quarterly in advance, but un- 
less paid annually, the accumulation feature of the policy is not 
included and neither is the beneficiary clause. Industrial accident 
insurance companies issue policies which pay a small amount for 
an accidental death and a certain amount of weeklv indemnitv 



56 HEALTH POLICIES 

when disability is caused by accident or disease. These com- 
panies generahy charge One Dollar per month for the insurance, 
and this is payable either weekly or monthly, according to the 
custom of the company that issues the policy. 



PART II 

HEALTH POLICIES 

Health policies as issued by accident insurance companies 
consist of two forms known as the general health or disabiUty 
policy and the special health policy. A new form of health poHcy 
has recently been issued by one of the large insurance companies, 
and is known as the unlimited health policy. This policy provides 
a new feature in health insurance, — namely, — it pays for partial 
disability following an illness which causes total disabihty. 

THE GENERAL HEALTH OR DISABILITY POLICY 
pays indemnity for disability due to any disease, with perhaps one 
or two exceptions, such as diseases of venereal origin or disability 
due or caused by over indulgence in alcoholic stimulants. These 
policies cost preferred risks Seven Dollars per year for each Five 
Dollars of weekly indemnity when the insured is between eighteen 
and fifty years of age, and Nine Dollars per year for each Five 
Dollars of weekly indemnity when the age is fifty to fifty-five 
years inclusive. Some insurance companies have an age limit of 
sixty years for the issuance of general health policies. The 
premium on a health policy is paid annually in advance, when 
the policy is issued by one of the larger companies. Industrial 
accident insurance companies collect their premiums also in ad- 
vance, but collect them weekly or monthly. These policies do 
not go into effect for disability until some days after the date on 
which they are issued. This time varies with different companies; 
usually fifteen days is the time allotted by the larger accident 
companies. Industrial accident companies do not put their health 
policies into effect until sixty to ninety days after the date of is- 
suance. 

THE SPECIAL HEALTH POLICY is issued by all of the 
large companies and pays weekly indemnity when the insured is 



I 



1 



UNLIMITED HEALTH POLICY 57 

totally disabled from performing the duties of his occupation by 
the diseases named in the policy. These policies cost Ten to Fif- 
teen Dollars a year, the amount being payable in advance, and 
pay Twenty-five Dollars per week for disability. Health insur- 
ance will not be issued on any individual unless that person is 
carrying an accident policy in the company to which he applies for 
a health policy. A medical examination is never required by an 
insurance company before the issuance of a health policy, unless 
the application shows something that would make such an ex- 
amination necessary or information unfavorable to the applicant 
is in possession of the company, when a medical examination is 
demanded before the policy is issued. 

THE UNLIMITED HEALTH POLICY was recently 
placed on the market by one of the large insurance companies. 
In addition to paying indemnity for an illness which causes total 
disability, this policy allows partial disability following total dis- 
ability on account of illness if the insured loses at least one-half 
of the business time each day on account of the disease which 
causes the disability. This is the first policy issued by any insur- 
ance company in the United States which pays for partial disabil- 
ity under a health policy, — all of the others paying partial indem- 
nity for total disability, but usually not requiring confinement to 
the house. This policy as just issued, while it pays total and 
partial disability for an illness, is sold at an advance over the price 
usually asked for a regular health or disability poHcy. 

COMBINATION POLICIES: General health policies are 
often combined with accident policies, the company issuing one 
policy covering disability for accident or disease, and these poli- 
cies are known as Combination Policies. This form is the one 
usually purchased by an individual when a general health policy 
is carried, for the reason that he must carry accident insurance, 
and therefore it is easier to combine the policies under the name 
of a combination policy, which pays disability for an accidental 
death and weekly indemnity for accidents and diseases. Under 
general health policies the following conditions or similar ones 
are usually found. 

PERMANENT DISABILITY: "If the insured shall con- 
tract during the term of this policy any disease that shall not 
result in death, but shall result independently of all other causes 
within one year from the date of this insurance, in the irrecover- 
able loss of the sight of both eyes or any permanent paralysis 



58 HEALTH POLICIES 

whereby the insured shall entirely lose the use of both hands or 
both feet or of one hand and one foot and on account of either of 
said conditions be permanently disabled from engaging in any 
work or occupation for wages or profit, the company will pay to 
him upon the filing at the company's home office, of satisfactory 
proofs of the continuance for fifty-two consecutive weeks of such 
blindness or paralysis $ of the principal sum, which pay- 
ment shall terminate the poHcy." This clause obligates the com- 
pany to pay a certain sum of money for permanent disability when 
loss of sight of both eyes is suffered, or from permanent paralysis 
when it occurs to two or more of the extremities. Some com- 
panies do not pay this indemnity until the end of the second year. 
This would require one year of total disability from the above 
causes and then another year following before the indemntiy 
would be payable by the insurance company. This is for the pur- 
pose of protecting the company against the payment of a claim 
for temporary disability, even though it may last almost two years. 
TOTAL DISABILITY: "If the assured shall suffer from 
bodily disease or illness not hereinafter excepted, and such dis- 
ease or illness shall wholly disable and prevent the insured from 
performing any and every kind of duties pertaining to his busi- 
ness or occupation, the company will pay to him the weekly in- 
demnity above specified for the period of such disability during 
which time he shall necessarily be confined to the house, and any 
disability of less than seven consecutive days or in excess of 
twenty-six weeks is not covered." Some general health policies 
pay indemnity for disability when less than a week is lost and 
some do not require house confinement as one of the conditions 
of the payment of total disability, but they usually limit the liabil- 
ity to twenty-six weeks or less. An insurance company will not 
pay total disability to an individual unless a legally qualified and 
licensed physician has been in attendance during the period of 
total disability. Some companies pay double the amount of weekly 
indemnity when the claimant is confined in a hospital during the 
illness. Industrial accident insurance companies do not pay total 
disability under the health feature of their policies until after the 
individual is totally disabled and confined to the house for one 
week, that is to sa}^ in order to receive one day of total disability 
under the health policy, he must be confined to the house eight 
days. These companies will pay the first week of disability when 
the individual is confined to the house by an illness, if he pays an 



PARTIAL INDEMNITY FOR TOTAL DISABILITY 59 

additional premium, and this is usually Twenty-five or Fifty Cents 
per month. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY: 
This clause is sometimes included in a general health policy, and 
if present it pays a certain percentage of the weekly indemnity for 
total disability when the claimant is not confined to the house or 
when he is recuperating after an illness which has caused total 
disability and house confinement. The amount paid is usually 
two-fifths of total disability and the time is limited; a short time 
only being allowed for this form of indemnity due to total dis- 
ability while recuperating. 

SURGICAL INDEMNITIES: 'Tf such disease or illness 
shall necessitate an operation specified in the schedule of surgical 
operations and such operation is performed by a legally qualified 
surgeon, the company will pay the insured, in addition to any 
other indemnity to which he may be entitled, the indemnity stipu- 
lated in said schedule for such operation, provided the operation 
occurs within ninety days of the contraction of such disease or 
illness, the company not to be Hable for more than one operation 
necessitated by such disease or illness." All disability policies al- 
low a fixed sum for surgeons' fees when such become due under 
the conditions of the above clause, and this amount is payable in 
addition to the weekly indemnity allowed by the policy. 

QUARANTINE INDEMNITY: 'Tf while this policy is in 
force the insured is exposed to any disease or illness and in con- 
sequence of such exposure is quarantined by a legally qualified 
public officer, and in consequence of such quarantine is rendered 
continuously unable to transact an}^ and every part of his business 
duties, the company will pay the insured the weekly indemnity 
provided hereunder during such period of quarantine not to ex- 
ceed •. consecutive weeks, provided proofs of such quar- 
antine are furnished to the company at its home ofiice within 

weeks of the termination of the quarantine." This 

clause is usually included in general disability policies and when 
found a part of such it pays indemnit}^ for a specified number of 
weeks when disability is due to this cause. This time is seldom 
over ten or twelve weeks and notice of such quarantine must be 
sent the company within a specified or reasonable time, the same 
as required by an accident insurance policv for notice of injnrv. 

SPECIAL HEALTI-I POLICY: A special health' policv 
pays for total disabilitv when the insured is tot all v disabled and 



60 HEALTH POLICIES 

prevented from performing any of the duties of the occupation^ 
provided the disabihty is caused by certain diseases or illnesses 
which are enumerated in the poHcy. These diseases vary ac- 
cording to the company which issues the insurance; some com- 
panies paying indemnity for disabilit}^ arising from any one of ten 
or fifteen diseases, while others include as high as thirty or forty 
diseases. This policy costs Ten to Fifteen Dollars per year for 
Twenty-five Dollars of weekly indemnity for ages under fifty 
years and the limit of liability on the part of the company is. 
twenty-six weeks. A number of diseases which are included in 
the policy are not very prevalent. A special health policy does not 
always require continuous house confinement as one of the condi- 
tions under which indemnity is payable, but usually pays the in- 
sured for the time that he is totally disabled by any of the diseases 
named in the pohcy. 



CHAPTER V 

INJURIES AND DISEASES OF THE HEAD AND NECK 

CAUSED BY ACCIDENTS AND RESULTING 

IN DISABILITY 

PART I 

INJURIES TO THE SCALP 

ABRASIONS 

INFORMATION : Abrasions of the scalp are not seen fre- 
quently except in individuals who have become bald through age 
or other reason, when an abrasion can be sustained accidentally 
by the head coming in violent contact with a harder substance. 
On account of the round contour of the skull, abrasions of the 
scalp usually involve only a small area and when such an injury 
occurs there is danger of an infection following. 

SIGNS AND SMYPTOMS come on at once after the 
abrasion has been sustained and consist of a swelHng which is 
usually out of proportion to the injury received. The skin is 
broken and slight bleeding follows, this soon coagulates and forms 
a scab over the abraded surfaces, headache is complained of and 
sometimes pain in the eyes after continued use for any length 
of time. If the blow which produced the abrasion has been se- 
vere, there may be a slight concussion of the brain, in which event 
headache will persist from three to seven days and in addition 
there may be some nausea or vomiting. For injuries involving the 
brain see Concussion of the Brain. 

DIFFERENTIAL DIAGNOSIS: Fraudulent Claims for an 
accidental injury alleging an abrasion of the scalp as the cause of 
disability are very rare, although it is possible for an individual to 
claim a brain injury following a more or loss severe abrasion: in 

61 



62 INJURIES INVOLVING THE SCALP 

which event notice of injury will probably not be received by the 
company until after evidence of the abrasion had disappeared and 
no chance would be given the compan}- to demonstrate that dis- 
ability existed; symptoms only being present when the examina- 
tion is made. 

Fxzema Capitis in the erythematous stage may sometimes be 
claimed as the result of an abrasion, but usually this disease will 
cover a larger area of the scalp than would an abrasion. This 
form of eczema may have some few openings with slight bleeding 
and thus resemble an abrasion which has been received accident- 
ally, but in this disease there is almost always a history of previous 
attacks, and each attack is accompanied with intense itching which 
is not present when the inflammation is caused by an accident, 
neither is there often any evidence of recent bleeding, such as is 
found in an abrasion. 

COMPLICATIONS : Infection of an abrasion of the scalp 
may follow and more frequently involves that part which is cov- 
ered with hair. When an abrasion occurs on the scalp of an indi- 
vidual which has been denuded of hair, there is less chance of an 
infection. Disability often results when abrasions become infected 
and this would not occur if the wound had remained aseptic. 

Erysipelas: Any injury which breaks the skin on any part of 
the body may be followed by this disease. If such an attack oc- 
curs, the beginning is from two td*seven days after the injury has 
been received, and when the disease follows small wounds, it is 
generally lighter than if larger surfaces had been involved. 

TOTAL DISABILITY for an abrasion of the scalp should' 
not be allowed unless there have been multiple abrasions and these 
have become infected. In a moderately severe abrasion of the 
scalp occurring to an individual whose occupation requires con- 
stant contact with people, this disability may last from 3 to 7 
days; after w^hich time the bandages that have caused the 
disability can be removed with safety and the individual return to 
his occupation. Claimants whose duties do not require contact 
with people, are seldom totally disabled more than from i to 3 
days. If an ordinary infection follows, this period of total disabil- 
ity may last from i to 2 weeks. Should erysipelas develop in the 
wound, total disability lasts from 2 to 3 weeks in mild cases and 
severe ones from 3 to 5 weeks before recovery is complete. 

PARTIAL DISABILITY is not deserVed in any case in 
which an abrasion of the scalp has occurred. 



CONTUSIONS OF THE SCALP 



63 



EFFECTS : After an injury as above described has been 
healed, — even though it has been attended with compHcations, — 
there rarely remains any evidence of the accident and the indi- 
vidual is insurable for any kind of a policy as soon as recovery has 
been complete. 

CONTUSIONS OF THE SCALP 

INFORMATION: Contusions of the head and scalp are 
commonly seen, but usually disability does not result unless the 
injury has been very severe or another part of the body is also 
involved. Frequently a contusion in this situation is accompanied 




FIG. 1.— LOCATION OF VARIOUS HEMORRHAGES IN THE SCALP. (Eisendrath). 

SK and AP represent the cutaneo-aponeurotic layer; P, pericranium; S, skull; 1, 
superficial hematoma or confusion in skin proper of scalp; 2, hemorrhage or pus- 
formation in subaponeurotic layer; 3, subpericranial hemorrhage. 

by an abrasion, and on account of the abrasion an infection may 
follow. Fraudulent claims are sometimes made against an insur- 
ance company when the disability is alleged to have been caused 
by a swelling accidentally received; such a swelling when present 
may be due to a tumor or cause other than a contusion. 

SIGNS AND SYMPTOMS: Immediately after a contusion 
to the scalp, the individual is more or less stunned. Then follows 
a swelling which is due to hemorrhage into the injured part, and 
later, on account of the hemorrhage, discoloration takes place. 
There is tenderness on pressure, headache, and in many cases 
nausea and vomiting; especially is this true if the contusion has 



64 



INJURIES INVOLVING THE SCALP 





Fig. 2. — Splintering of inner table of 
the skull; cross-sections diagrammatic; 
a, Usual form of fracture; b, a linear 
fracture more extensive internally than 
externally. (Scudder) 



been severe enough to cause any brain injury. For injuries of 
the brain following contusions, see Concussion of the Brain. 

DIFFERENTIAL DIAGNOSIS: Depressed Fracture of the 
skull may complicate a contusion. If this condition exists, the 
edge of the fractured bone is usually depressed below the level of 
the contour of the skull, while a hematoma due to a blow is sit- 
uated above or on top of the skull. Shock is always present in a 
fracture of the skull and may persist for some time, but never 
follows simple contusions. 

COMPLICATIONS sel- 
dom follow a slight contusion of 
the scalp. If the blow has been 
a severe one and the brain 
lacerated or torn, complications 
may arise; in which event see 
Concussion of the Brain. 

Septic Osteomyelitis may fol- 
low a hard blow to the scalp, 
w^hen the signs of the localized 
inflammation will become very 
severe and be attended with constitutional symptoms, such as loss 
of appetite, chills, and irregular and high fever. 

Necrosis of the bone underlying the contusion is possible; if 
this supervenes the prognosis is bad and a release should be ob- 
tained by paying a sum that seems unreasonable, but w^hich is for 
the best interests of the company. 

Boils may sometimes be claimed as the result of a blow and 
indemnity demanded under an accident policy, but as they seldom 
follow a contusion, it is not often that indemnity is payable. 

An Abscess of the scalp may follow a contusion, and if it 
forms beneath the pericranium, it is limited in area to the out- 
lines of the bone of the skull over which it is found. Should the 
abscess develop between the occipito-frontalis muscle and the 
pericranium, it may travel over the whole top of the skull. Locally 
an abscess is characterized by swelling and a dusky discoloration 
which does not pass through the different stages of a discolora- 
tion resulting from extravasated blood. The temperature is gene- 
rally elevated when an abscess is situated in this region; in addi- 
tion there is a throbbing pain which becomes worse when the in- 
dividual is in a recumbent position. 

Tumors of the scalp are usually sebaceous cysts and some- 



INCISIONS OP THE SCALP 65 

times the sac is ruptured by a slight blow on the head, in which 
case disability or the resulting abscess, if it occurs, is said to be 
due to a contusion, and indemnity is claimed under an accident 
policy. Unless the sac has been ruptured in some manner, there 
should be no mistaking a tumor for a contusion. 

TOTAL DISABILITY does not follow sHght contusions of 
the scalp, unless there is an accompanying abrasion, and this be- 
comes infected. In these cases total disability may occur and last 
from 3 to 7 days. If an abscess develops as the result of a con- 
tusion in this region of the bod}^, total disabihty ensues and lasts 
from I to 2 or 3 weeks, depending on the size and location of the 
collection of pus, but this disability does not begin until from five 
to ten days after the accident has been sustained. 

PARTIAL DISABILITY is not payable for contusions of 
the scalp unless there has been a resulting brain injury, when it 
is due to the damage done inside of the skull and not to the scalp 
alone. 

EFFECTS : Simple contusions of the scalp produce no bad 
effects, and have no bearing on the insurabiUty of an individual 
for any kind of a policy. 

INCISIONS OF THE SCALP 

INFORMATION : Incised wounds of the scalp are produced 
by some sharp instrument and result in cleanly cut edges of vary- 
ing length and depth, and if properly treated, healing is rapidly 
accomplished on account of the large blood supply to this part of 
the body. 

SIGNS AND SYMPTOMS : Severe and sharp pain occurs 
at the time an incision is made and this in turn is followed by 
hemorrhage, which depends on the size of the incision. If the cut 
is long and deep, hemorrhage is a prominent sign and persists for 
a considerable time. Gaping of the wound edges is almost always 
met with in this kind of an injury. 

COMPLICATIONS: Erysipelas may follow an incised 
wound, and if it does, disability will be caused by the complica- 
tion and not by the incision, and the duration of disability will be 
governed by the complication. 

TOTAL DISABILITY follows in preferred risks when an 
incision of the scalp has been sustained, and lasts from 3 to 7 
days: if the wound has become infected, this disability may per- 



66 INJURIES INVOLVING THE SCALP 

sist from 7 to 14 days. Total disability in this class of risks is not 
due to the injury alone, but is caused by the party refusing to go 
to his place of business with the head covered by a bandage. In- 
dividuals insured under the ordinary classification should not be 
totally disabled more than from i to 3 days unless infection fol- 
lows, w^hen this disability may recur after the occupation has 
been resumed for several days, and lasts from 3 to 7 days. 

PARTIAL DISABILITY is not deserved under an accident 
policy to any class of risks suffering from an incision of the scalp. 

EFFECTS : A scar usually results from an incision of the 
scalp, but unless the wound suppurated and healing was delayed, 
it is so small that it rarely shows. This is especially true if the 
incision has occurred in a part that is well covered by hair. 

LACERATIONS OF THE SCALP 

INFORMATION: Lacerated wounds of the scalp are 
usually associated with contusions and are produced by any blunt 
instrument coming in violent contact with the skull and forcibly 
tearing asunder its covering. The cut in a laceration is usually 
ragged, and in many cases foreign particles are carried into the 
tissue and this results in an infection which prolongs disability. 

SIGNS AND SYMPTOMS: The edges of a lacerated 
wound are irregular, gapping, shreddy and covered^ with blood 
clots. Hemorrhage is usually slight on account of the laceration 
and contusion of the tissues, which produces a larger injured sur- 
face and thus allows the blood to coagulate. Lacerated wounds 
of the scalp produce greater shock than do incised wounds, but 
there is less pain, which is of a dull and aching character. When 
the tearing has been very severe and extends over considerable 
area, reactionary and secondary hemorrhages occur; these appear 
about the time the damaged tissue sloughs and is thrown off by 
nature. 

COMPLICATIONS : Infection is more apt to occur in a lac- 
erated wound on account of foreign bodies which may be carried 
into the cut, than if the wound edges have been cleanly separated. 

Erysipelas may also follow a lacerated wound and is more 
prone to do so in this portion of the body than in others. When 
it follows, this inflammation begins some few days after the 
wound has been received. 

TOTAL DISABILITY: Preferred risks suffering from a 



PUNCTURED WOUNDS OF THE SCALP 67 

laceration of the scalp of from one to three inches in length and 
without brain symptoms, require from 3 to 7 days of total dis- 
ability before resuming the duties of their occupation. If an in- 
fection follows, this disabihty may last from 7 to 14 days. Ordi- 
nary risks usually demand from 2 to 7 days of total disability with- 
out regard to infection. 

PARTIAL DISABILITY following a laceration of the scalp 
is not often demanded, and unless there has been more or less 
concussion to the brain and the individual is a preferred risk, this 
disability should not be allowed. If it is necessary to pay partial 
indemnity for any reason, from 7 to 10 days are generally suffi- 
cient. 

EFFECTS : Lacerations that are long and deep usually leave 
permanent scars, the prominence of which depends on the amount 
of tissue lost at the time of the accident and the degree of infec- 
tion. The hair does not grow from a scar, but it is usually cov- 
ered by that from surrounding parts. 

PUNCTURED WOUNDS OF THE SCALP 

INFORMATION: Punctured wounds of the scalp which 
are produced by sharp-pointed instruments, such as pins, needles, 
trocars, etc., produce small wounds and permit a quick recovery, 
unless a part of the instrument has been broken ofif and remains 
in the wound or an infection follows. Wounds made by daggers 
are generally punctured and incised wounds combined, the inci- 
sion usually being made when the instrument is withdrawn. 

SIGNS AND SYMPTOMS : Punctured wounds of the scalp 
produce few symptoms; slight hemorrhage, sometimes a head- 
ache lasting a short time, retraction and turning in of the wound 
edges and later an infection may follow with a discharge of pus. 
Punctured wounds of the scalp which become perforating wounds 
of the skull, produce evidence of brain injury, and for a description 
of this see Punctured Wounds of the Skull. 

COMPLICATIONS: Infection is the most common compli- 
cation following a punctured wound of the scalp and is due to im- 
proper cleaning of the puncture on account of its nature. 

Erysipelas may develop in any punctured wound and cause 
disability where none would exist if the puncture healed by first 
intention. 

Tetanus is a complication that often follows this form of injury 



68 INJURIES INVOLVING THE SCALP 

to the scalp when it has been caused by any instrument that may 
carry the germs of this disease. It is more Hkely to foUow a 
wound of this kind when the injury has been caused by a rusty 
nail or some implement which is in use around a barn yard. 
Wounds from fire-arms, especially from Avads of blank cartridges, 
frequently produce the disease. 

TOTAL DISABILITY does not follow from uncomphcated 
cases of punctured wounds of the scalp in any class of risks. When 
a complication ensues, this period of disability wall depend on the 
cause, — if an ordinary infection, — a preferred risk may demand 
from 3 to 7 days. Individuals insured under the ordinary classifi- 
cation seldom require any total disability, even if a punctured 
wound of the scalp becomes infected. If erysipelas or tetanus 
develops, see the description under either of these headings for 
the length of disability. 

PARTIAL DISABILITY is not deserved in any class sul- 
lering from a puncture to this part of the body. 

EFFECTS : Punctured wounds of the scalp which heal by 
lirst intention and are not infected, produce small scars. If the 
puncture penetrates the skull, or erysipelas or tetanus develops, 
the individual is not insurable for any kind of a policy for a con- 
siderable time after the injury has recovered, this depending on 
the nature of the complication. 

,; BURNS AND SCALDS OF THE SCALP 

INFOR]\IATION : Burns and scalds of the scalp result from 
a number of causes, the most common of which are exposure to 
high heat, flames, boiling liquids, steam, over-heated metals, acids 
and caustic alkalies. Scalds from liquids and steam — unless severe 
— do not cause destruction of the hair follicles over the area in- 
volved, but when flames, heated metals or acids come in contact 
with the scalp and produce a severe burn, they are usually de- 
stroyed, resulting in permanent loss of the hair. Severe burns to 
the scalp may result in inflammation of the brain and this end in 
death. 

SIGNS AND SYMPTOMS depend on the area of the burn 
or scald. There is, however, in all cases, an inflammation with 
swelling, accompanied by a blister or carbonizing of the parts 
involved. Slight injuries of this class produce pain and in ner- 
vous individuals some shock. Severe burns or scalds produce a 



BURNS AND SCALDS OF THE SCALP 69 

decided shock, with much pain, swelHng and loss of hair over the 
affected parts. 

DIFFERENTIAL DIAGNOSIS: Pemphigus is an inflam- 
matory disease of the skin characterized by blebs or bullae which 
vary in size. This disease may sometimes be claimed as a burn 
from the result of an accident, but the fact that these blebs are 
not surrounded by an area of inflammation and usually appear in 
crops and are attended with intense itching and burning and are 
found in individuals whose system is greatly debilitated or in 
women during menstruation or pregnancy, makes the diagnosis 
not difhcult. 

COMPLICATIONS: Infection and Suppuration are frequent 
sequelae following a burn or scald to this part of the body. 

Erysipelas is liable to develop after a burn or scald and there- 
by prolong the period of disability. 

Pyemia and Septicemia are complications which arise and 
greatly prolong disability following these injuries. 

Tetanus may be contracted, although it is not usual for this 
complication to arise after a burn or scald; if it does, disabihty 
may be greatly prolonged if the individual survives, but usually 
death ensues in a short time. 

TOTAL DISABILITY: Preferred risks suffering from a 
moderately severe burn or scald of the scalp which does not in- 
volve a large area, require from 7 to lo days absence from work. 
If the burn is severe, but small in size and in the same class of 
risks, from i to 2 weeks are necessary. When the burn is deep 
and involves a large portion of the scalp, total disability in any 
class of risks lasts from 4 to 6 or 8 weeks. Individuals insured 
under the ordinary classification and suffering from a moderately 
severe burn to this part of the body, usually demand from 3 to 
10 days only. If skin grafting is necessary, each operation gene- 
rally prolongs disability from 2 to 3 weeks. 

PARTIAL DISABILITY is not often necessary in injuries 
as above described in any occupation, unless the burn or scald 
has been very severe and total disability has lasted a considerable 
time. In which event partial disability of from i to 3 weeks may 
be demanded on account of the weakened condition following this 
period of total disability. 

EFFECTS : Burns and scalds of the scalp which do not go 
beyond the formation of blisters leave no permanent scars. AMien 
the deeper tissue has been destroyed, the resulting porniaiient 



70 INJURIES INVOLVING THE FACE 

scar is at first red and later becomes white, blanched and contract- 
ing, and over this surface the hair does not grow. There is no 
impairment of insurability of an individual who has suffered from 
a severe burn or scald of the scalp alone. Complications which 
may have arisen will determine the insurability for any kind of a 
policy. 



PART II 

INJURIES TO THE FACE 

ABRASIONS 

INFORMATION : Abrasions of the face are usually the re- 
sult of the skin of the face coming in violent contact in a sliding 
manner with a substance more or less hard and rough. When 
the skin is broken and abraded over a large area, there are usually 
a number of smaller abrasions surrounding the main one. Infec- 
tion may follow in one or more of the open places of the skin 
when the signs and S3'mptoms are aggravated and the resulting 
scar, if an}^ is more noticeable. It also causes a prolongation of 
the healing of the wound and may produce disabilit}^ when it is 
not already existing. 

SIGNS AND SYMPTOMS: Immediately following an 
abrasion which has been received accidentally, there is a swelling 
and redness of the injured parts which does not last more than 
twenty-four to forty-eight hours, the skin is broken in a number 
of places and from these points a slight bleeding ensues; later a 
scab forms over the abraded surface, the swelling and redness dis- 
appear and unless the wound has become infected, healing pro- 
ceeds until the process is completed. Should an infection occur, 
pus forms and discharges from a number of small points, but 
usually this does not take place in an abrasion of the face; such 
injuries generally healing bv first intention. 

DIFFERENTIAL DIAGNOSIS : Abrasions of the face are 
seldom produced intentionally, for the reason that an individual 
who intends to defraud an insurance company selects another part 
of the body for producing signs of an injury. Abrasions in this 
position, however, may be mistaken for certain diseases, and it is 
important that the diagnostic points be knovrn. 



ABRASIONS OF THE FACE 



71 



Erythema Simplex is an acute affection of the skin which pro- 
duces a slight local increase of temperature and discoloration in 
spots, which are sometimes small and isolated, and at other times 
large and diffused over a considerable area. In this disease, how- 
ever, there is a slight itching and burning of the skin which is 
not present in an abrasion at the same time. Abrasions usually 
have a burning sensation immediately after being sustained, and 
as the healing process proceeds, a slight itching may be com- 
plained of, but rarely. 

Erythema Intertrigo is an acute congestion of the skin charac- 
terized by an abraded surface with heat, redness, perspiration and 
maceration of the epidermis. This condition of the skin is most 




Fig. 



-Eczema of the face. (Stelwagon). 



frequently encountered when two surfaces are brought in contact 
with each other, but may sometimes be seen in connection with 
the face or neck. The perspiration which accompanies this in- 
flammation and the maceration of the skin are not found when an 
abrasion occurs and are sufificient for making a diagnosis between 
the disease and an accident. 

Eczema is one of the most common diseases of the skin and 
presents the general characteristics of a catarrhal inflammation, 
including diffuse persisting redness, heat, swelling and a discharge 
of serous fluid which becomes incrusted. Eczema in the pustular 
stage with few scattered pustules may sometimes be mistaken 



72 INJURIES INVOLVING THE FACE 

for an infected abrasion, but careful questioning will soon estab- 
lish the proper diagnosis. 

COMPLICATIONS: Infection rarely follows an injury as 
above described, but when it does disability may be prolonged 
several days or more. 

Erysipelas is one of the most frequent complications that may 
follow an abrasion to the face, and usually begins from two to 
seven days after the injury has been received, first showing itself 
by redness around the alae of the nose and spreading from these 
points until it involves more or less of the face. 

TOTx\L DISABILITY, rarely results when an abrasion of the 
face is the only injury sustained, unless the accident has been very 
severe and injured a large area; in which event an individual who 
is classed as a preferred risk will usually not return to his occupa- 
tion until his face is presentable, and this requires from 3 to 7 
days; should an infection follow, this total disability lasts from I 
to 2 weeks. If the claimant is insured under an ordinary classifi- 
cation and his occupation does not require contact with people, 
total disability seldom lasts more than from i to 3 days. When 
an abrasion of the face is complicated with an attack of erysipelas, 
total disability lasts from 2 to 3 weeks in ordinary cases and in 
more severe ones from 3 to 5 weeks may be necessary before the 
individual can resume his occupation. 

PARTIAL DISABILITY is not allowable to any class of 
claimants, for the reason that an individual who can do any part 
of his w^ork, can do all of it. 

EFFECTS : There is seldom any resulting scar unless the 
abrasion has been very extensive and has been followed by an 
infection, when there may be a superficial scar which is red at 
first and gradually fades, even in these cases all elTects of the 
abrasion usually disappear in two to three months. 

CONTUSIONS OF THE FACE 

INFORMATION: Contusions of the face are produced by 
blows which are received while the body is in an upright position 
and also when the face strikes a hard substance in falling. Insur- 
ance companies will not pay for disability resulting from blows to 
the face or head which are received in an altercation, but if an in- 
dividual is assaulted by unknown persons and disability results 



INCISIONS OP THE FACE 73 

from contusions or other injuries, indemnity is payable under an 
accident policy. 

SIGNS AND SYMPTOMS: Immediately after a blow has 
been received, swelling and redness appear, and this is especially 
marked when the injury has been received in the region of the 
eyes or mouth. Swelling may be so great when the blow has been 
over an eye, that this organ will be completely closed. There is 
pain and tenderness over the injured part and in from ten to 
twenty-four hours discoloration ensues — being more marked in 
the dependent area — and remains three to seven days or longer. 

DIFFERENTIAL DIAGNOSIS: Tumors of the face re- 
semble a contusion and especially when there is an area of inflam- 
mation surrounding the mass, but in such cases the well marked 
signs of discoloration which appear from a blow are not apparent 
at any time. 

Parotitis: Inflammation of the parotid gland may sometimes 
be claimed and mistaken as the result of an accident, especially if 
there is a history of a blow having been received in the region 
of the ear. Excessive swelling of this gland extends and involves 
the side of the face, but there is no discoloration following and 
the fact that the gland of the opposite side is frequently affected, 
and in some cases the testicles, serve to make a differential diag- 
nosis. 

Brighfs Disease causes swelling under the eyes, which may be 
very extensive, but there is no discoloration following, and in ad- 
dition there is evidence of this disease in the urine and the swollen 
abdomen and ankles 

TOTAL DISABILITY: Preferred risks suffering from a 
contusion to the face usually require from 2 to 7 days of total dis- 
ability, for the reason that pride keeps them from their occupa- 
tion. Ordinary risks are not entitled to this disability from a 
simple contusion. 

PARTIAL DISABILITY should not be allowed to any class 
of risks, unless the eyes or ears have been involved and the occu- 
pation requires considerable use of one or both: in which case 
from 2 to 7 days are sometimes necessary. 

EFFECTS: None. 

INCISIONS OF THE FACE 
INFOR]\L\TrON: Incisions of the face usually result from 



74 INJURIES INVOLVING THE FACE 

cuts by an instrument with a sharp edge and often from glass; 
unless the incision penetrates the mouth, heahng is quickly ac- 
comphshed. Incised wounds of the face when received in fights, 
are not covered for disabiUty under an accident policy, and in- 
demnity is not payable wdien the wound is sustained under such 
conditions. 

SIGNS AND SYMPTOMS: At the time the incision is 
made or immediately following it, there is a sharp stinging pain, 
with hemorrhage and separation of the wound edges. If the inci- 
sion is deep enough to penetrate the nasal or bucal cavities, evi- 
dence of communication between them and the external surface 
is apparent. 

COMPLICATIONS : Infection may follow an incised wound 
of the face and cause a prolongation of the disability, but this com- 
plication is not usual unless the cut penetrates into one of the 
cavities, when the w^ound usually becomes infected and the dura- 
tion of disability is uncertain. 

Erysipelas and Tetanus may also occur as complications. 

TOTAL DISABILITY following incisions to any part of the 
face which do not penetrate either one of the cavities and which 
are not infected, require from 7 to lo days when seen in pre- 
ferred risks. Infection increases this time about i week. Indi- 
viduals in the ordinary class usually demand from 2 to 5 days 
of this disability. When either of the nostrils or the bucal cavity 
is opened by an incision, total disability lasts from 2 to 3 weeks 
in preferred risks. Ordinary risks generally require about 2 
weeks under these conditions. 

PARTIAL DISABILITY is not deserved by any class of 
risks. 

EFFECTS : A scar follows an incision to any part of the 
face and is more or less prominent according to its size, depth aijd 
location, and whether an infection followed; usually, however, 
scars are slight and do not cause much disfigurement, unless the 
cut is a long one and no sutures have been applied, in which case 
an unsightly scar results. 

LACERATIONS OF THE FACE 

INFORMATION : Lacerated w^ounds of the face are more 
or less contused and may be produced by any substance which 
strikes the face hard enough to break the skifi and injures the un- 



PUNCTURED WOUNDS OF THE FACE 75 

deriving tissue. Disfigurement follows severe lacerated wounds 
of this part of the body, and especially if an infection occurs and 
a prolonged period of suppuration ensues. 

SIGNS AND SYMPTOMS: Evidence of the laceration, the 
cut generally extending in different directions followed by hemor- 
rhage, pain, sw^elling, discoloration and frequently infection. 

COMPLICATIONS : Any wound of the face which ruptures 
the continuity of the skin is liable to become infected by pus or- 
ganisms, erysipelas or tetanus, and if any of these develop, the dis- 
ability is prolonged according to the infection. 

TOTAL DISABILITY should not result from this class of 
wounds of the face, but individuals who are insured in the pre- 
ferred classes, such as store clerks, office help, and men engaged 
in different professions, usually require from 5 to lo days of this 
disability. This is due to the fact that this class of people will 
not return to their occupation wearing a bandage on the face. 
Ordinary risks may require from 2 to 7 days of total disability 
when the laceration is long and deep. If infection follows, this 
disability in all classes is prolonged about i wxek. 

PARTIAL DISABILITY is not deserved by any class of 
risks when a laceration of the face has been sustained, unless ery- 
sipelas or tetanus has followed, when it may be necessary in all 
classes of risks to allow^ from i to 3 wrecks of this form of dis- 
ability following the period of total. 

EFFECTS : A scar resulting from a lacerated wound and its 
prominence, depends on the depth of the laceration, its position 
and the method of treatmxent. These scars are red at first and in 
time fade to a whiteness which remains, and later contraction may 
follow, causing them to become more noticeable. 

PUNCTURED WOUNDS OF THE FACE 

INFORMATION: Punctured wounds of the face may re- 
sult from any sharp or blunt instrument which enters the skin to 
a greater or less extent. If the puncture goes into the nasal cav- 
ity or mouth or one of the bony cavities of the face, it becomes a 
penetrating wound. If it enters' the niouth or nose, treatment is 
not difficult, but if it reaches one of the l)ony cavities, infection 
usually occurs and the suppuration which follows causes a pro- 
longation of the disability and difficulty in treatment, ^^'ounds of 
the face produced by missiles from fire-arms arc almost without 



76 



INJURIES INVOLVING THE FACE 



exception penetrating in character, and if the fire-arm is exploded 
close to the face, a powder burn complicates the primary wound. 
SIGNS AND SYMPTOMS of this class of wounds involving 
the face are plainly evident, and are followed by pain, hemorrhage, 
swelling and discoloration, and when the puncture or penetrating 
wound has been made by fire-arms, gun powder may be embedded 
in the tissue surrounding the opening. Shock is usually com- 
plained of and the degree of severity depends on the character 
of the wound. 




Fig. 4. — Penetrating wound of face with powder marks. (Draper). 



COMPLICATIONS: Punctured Wounds which are of any 
depth usually become infected, thus prolonging disability and 
causing the resulting scar to be more prominent. 

Tetanus frequently follows gunshot injuries and especially if 
the wound has been inflicted by a blank cartridge. Disability is 
always prolonged in such cases and often termintes in death. 

Erysipelas may develop in the wound, when the disabilfty will 



BURNS AND SCALDS OP THE FACE 77 

be prolonged according to the length of time required by this dis- 
ease for recovery. 

TOTAL DISABILITY: If the puncture does not enter the 
cavities of the face or head, this disability usually lasts from 3 to 
10 days in preferred risks. Ordinary risks may require from 2 to 
5 days immediately following infliction of the wound. If the 
puncture becomes a penetrating wound and the instrument en- 
ters one of the cavities of the face, total disability in preferred 
risks may last from i to 4 or 6 weeks, depending on the depth 
of the wound, the amount of laceration of the superficial and deep 
tissues and the severity of the inflammation which follows. Ordi- 
nary risks who are not brought in contact with people, generally 
require from i to 2 or 3 weeks of this disability. Should erysipelas 
or tetanus develop, total disability is prolonged according to the 
time required for recovery by the complication. 

PARTIAL DISABILITY does not follow simple punctured 
or penetrating wounds of the face, unless total disability has 
lasted a long time and the physical condition of the individual is 
debilitated, when it may be necessary to pay from i to 2 or 3 
weeks of this disability to persons who are insured under a pre- 
ferred classification. 

EFFECTS : A scar results in all cases from punctured or 
penetrating wounds of the face, and its prominence depends on 
its cause, position, depth and the resrilting infection. Individuals 
are insurable for all kinds of policies from three to six months 
after complete recovery of these wounds, if the injury has not in- 
volved the eyes or brain. If one eye has been lost, an accident 
policy eliminating indemnity for the loss of one or both eyes can 
be issued if the occupation is not too hazardous. Life insurance 
can also be granted in the majority of cases. When the brain has 
been injured, insurance of all kinds must be denied the individual 
until at least from one to two years have elapsed and then each 
case must be considered separately. 

BURNS AND SCALDS OF THE FACE 

INFORMATION: Burns and scalds of the face occur fre- 
quently and especiall}^ the latter. They may be caused by ex- 
posure to steam, flames or contact with boiling liquids, over- 
heated metals, caustic alkalies and acids. These injuries, when 
at all severe, leave permanent marks, and when the deeper tissues 



78 



INJURIEiS INVOLVING THE FACE 



of the face have been destroyed, the scars contract and produce 
much disfigurement. 

SIGNS AND SYMPTOMS from burns or scalds depend on 
the degree of severity. If only the superficial tissues have been 
involved, there is pain, swelling, inflammation and later a slough. 
If the burn has been extensive and the deep tissues are involved, 
ithere is shock in addition to the above. When the face has been 
scalded by hot steam or boiling liquids, a blister only may result 
or the scald may be so severe that part of the tissues of the face 
are literally cooked and destroyed. If the latter case, there is 




Fij 



5. — Marked contraction following deep burn of face and neck. (Fowler). 



severe shock, swelling, inflammation, loss of tissue by suppuration 
and sloughing. 

DIFFERENTIAL DIAGNOSIS: Pemphigus may some- 
times be claimed as the result of an accidental scald, for the reason 
that the blisters which are characteristic of pemphigus vulgaris 
resemble those produced by an accident, but in this disease there 
is generally no circumscribed area of inflammation surrounding 
the bleb, and in addition there is constant pain and itching which 
may be slight or troublesome. When blebs of this disease rup- 
ture, a scab forms over the site of the blister and this does not 



BURNS AND SCALDS OP THE FACE 7» 

follow a blister produced accidentally, except when healing is al- 
most complete. 

COMPLICATIONS involving the eyes, ears, nose, mouth, 
throat or lungs may follow when burns and scalds are of such se- 
verity that these parts are involved. Disability is thus prolonged 
according to the organ affected. 

Infection, Erysipelas or Tetanus may develop in these wounds 
and cause lengthening of the period of disabiHty. 

TOTAL DISABILITY should not result from superficial 
burns or scalds of the face, but individuals who are insured under 
preferred policies remain away from their occupations from 3 to 
7 days on account of the appearance of the face. When the injury 
has been moderately severe, the face blistered and the skin par- 
tially destroyed over a small area, all classes of risks require from 
I to 2 weeks of total disability. When the injury has been severe, 
involving a greater part of the face, total disability lasts from 4 
to 6 weeks and even longer in some cases. CompHcations such as 
erysipelas or tetanus prolong the above mentioned period of dis- 
ability according to the time required for recovery of the compli- 
cation. If an operation for skin grafting is necessary, total disabil- 
ity is prolonged from 2 to 3 weeks each time the operation is per- 
formed. 

PARTIAL DISABILITY is not often paid following this 
class of injuries unless the burn or scald has been very severe, and 
on this account the physical condition has become greatly debili- 
tated when from i to 3 weeks of this disability may be demanded. 

EFFECTS: Superficial burns or scalds to the face do not 
leave any permanent mark. When the injury has destroyed the 
deeper layers of the skin or any of the muscular tissue, a perma- 
nent scar results, and if a great amount of tissue has been lost, 
contraction follows and much disfigurement is the result, this is 
especially true when the burn or scald involves the lips. If the 
burn or scald is deep and affects that part of the face of the male 
which is covered with hair, this ceases to grow. 



so INJURIES INVOLVING THE EYELIDS. 

PART III 

INJURIES TO THE EYELIDS 
ABRASIONS AND CONTUSIONS 

INFORMATION: Abrasions and contusions of the eyelids, 
either the upper or lower, usually follow from blows which involve 
the surrounding parts and are generally produced accidentally; 
seldom by intent. In the latter case, indemnity is not payable 
under an accident policy when disability follows a blow which in- 
volves the eyes and which has been received in an altercation with 
another person, unless the blow was received when the individual 
had been attacked by highwaymen. 

SIGNS AND SYMPTOMS : Immediately following the in- 
jury, there is swelling with pain in the eyeball and later discolora- 
tion of the lids and surrounding parts. If the injury has been an 
abrasion, there is a slight bleeding which gradually ceases and 
scabs form over the abraded parts. There is usually a watery 
discharge from the eyes following a blow to this part of the body, 
and this persists for several days. 

COMPLICATIONS: Ptosis or drooping of the upper lid is 
occasionally due to blows which result in paralysis of the third 
nerve supplying the levator palpebrce muscle. If due to a blow 
evidence of the injury is apparent one to two weeks after the acci- 
dent. Cases of any standing show wrinkling of the forehead, due I 
to constant attempts of trying to elevate the lid b}^ the occipito- 
frontalis muscle. 

TOTAL DISABILITY is payable as the result of these acci- 
dents, and in preferred risks requires from 7 to 10 days. Ordinary 
risks who are not required to use the eyes generally ask from 3 
to 7 days of this disabilit3^ Preferred risks would not be totally ; 
disabled more than from i to 3 days if pride did not keep the in- 
dividual away from work. This condition can be obviated by 
painting the discolored parts with water colors. 

PARTIAL DISABILITY of from i to 2 weeks may be de- 
manded by preferred risks when the occupation requires constant 
use of the eyes and the injury has been severe. No partial dis- 
abilitv should be paid to ordinarv risks. 

EFFECTS: None. 



INCISIONS AND LACERATIONS OF THE EYELIDS. 81 

INCISIONS AND LACERATIONS OF THE EYELIDS 

INFORMATION: These wounds are usually caused by 
sharp or blunt instruments which divide the tissues cleanly or in 
a ragged manner and frequently injure the underlying eyeball. 
Individuals who wear glasses are sometimes struck over the eye 
by missiles, breaking the glasses and causing incised or lacerated 
wounds of the eyelids and surrounding tissue and in many in- 
stances injury to the eye complicates the wound of the lids. 

SIGNS AND SYMPTOMS follow immediately, and depend 
on the character of the wound. A clean cut incision running 
longitudinally shows slight bleeding, but no gapping of the wound 
edges unless the lids are closed. When the cut runs in a perpen- 
dicular manner, the two extremities of the lid are pulled apart and 
exposure of the eyeball results if the incision has completely cut 
through the lid. Lacerations produce bleeding and uneven cuts 
which may extend through the lid and cause exposure of the eye; 
swelling and ecchymosis follow in both cases and a watery dis- 
charge which lasts from twelve to forty-eight hours. 

COMPLICATIONS: A number of complications may en- 
sue from a deep incision or laceration of the eyeballs, and these 
are described under Conjunctivitis. 

TOTAL DISABILITY follows these injuries in all classes 
of risks and lasts from i to 3 weeks, depending on the extent of 
the incision or laceration. If a complication ensues, disabihty 
may be prolonged from i to 3 weeks. 

PARTIAL DISABILITY of from i to 4 weeks may be 
necessary in preferred risks when the occupation requires much 
use of the eyes. 

EFFECTS : A scar results and the degree of deformity de- 
pends on the location of the injury, its severity and also the suc- 
cess of the attending surgeon in repairing it. These scars are 
permanent and on account of the contracting which may ensue, 
deformity may become more marked. Unless the eyeball has 
been injured, individuals are insurable for any kind of a policy as 
soon as recovery is complete. 

PUNCTURED WOUNDS OF THE EYELIDS 

INFORMATION: Punctured wounds to this part of the 
body almost always become perforating* wounds and cause injury 
6 



82 



INJURIES INVOLVING THE EYELIDS 



to the eyeball. They are produced by sharp-pointed mstruments 
or by missiles propelled by gunpowder and are usually infected, 
causing inflammation of the eyeball to result. 

SIGNS AND SYMPTOMS: Evidence of a puncture is 
apparent, showing a break in continuit}^ of the lid, with pain, bleed- 
ing, swelling and photophobia, accompanied by a watery discharge 
at first, which later becomes purulent in character. If the punc- 
ture is the result of an injury by a fire-arm, the eye is usually de- 




Fig. 



-Punctured wound of left eye without powder marks. (Draper). 



stroyed and there is a discharge of the contents of the orbital 
cavity, producing entire loss of sight in the injured eye. 

COMPLICATIONS follow injuries of this character and are 
described under Conjunctivitis. 

TOTAL DISABILITY: When the puncture has not pene- 
trated the lid and involved the eyeball or when it does penetrate 
but does not injure the underlying organ, total disability in all 
classes of risks lasts from 5 to 10 days. If the punctured wound 
injures the ball of the eye, total disability is prolonged and per- 
sists for the time that the complication requires for recovery. In- 
juries which destroy the eyeball, thus necessitating a surgical oper- 
ation for the removal of the same, requires from 3 to 6 weeks for 



BURNS AND SCALDS OF THE EYELIDS 83 

a complete recovery, but as accident policies generally pay a 
specific sum for the loss of an eye, this time is not important. 

PARTIAL DISABILITY of from i to 2 or 3 weeks may 
follow in preferred risks when a punctured wound of the eyelid 
penetrates and injures the eyeball. If total disability lasts for a 
considerable time, partial disabiHty may be increased, depending 
on the cause of the primary total disability. 

EFFECTS : If the puncture is only a small one and does not 
penetrate the lid, the resulting scar is invisible. Should the punc-, 
ture penetrate the hd and destroy any part of it, there may be a 
resulting scar which is sufificient toxause a slight deformity. When 
the eyeball is destroyed as the result of a puncture, deformity is 
permanent and its degree depends on the amount of destruction 
of tissue at the time it was inflicted and also on the success of the 
operation for the removal of the ball. Individuals who have suf- 
fered the loss of one eye are impaired risks for accident insurance, 
although some companies will issue an accident policy to persons 
who are only supplied with the use of one eye, — when the loss of 
the other eye has been sufl^ered some years previously. When 
there is only one good eye, a life or health policy will usually be 
issued to persons without any restriction. 

BURNS AND SCALDS OF THE EYELIDS 

INFORMATION : These injuries may be produced by boil- 
ing liquids, steam, acids, caustic alkalies, etc., which come in con- 
tact with the open or closed lids. If the injury does not involve 
the eyeball and only affects the lids, disability is short. If the in- 
jury results in a destruction of the tissue of the eyelids or the 
eyeball itself, disability is long and deformity is permanent. When 
the eyelids are burnt or scalded there is usually an injury of the 
same character to the surrounding tissue. 

SIGNS AND SYMPTOMS depend on the cause of the burn 
or scald. Steam and boiling liquids produce blisters with inflam- 
mation, swelling, pain and a watery discharge. Strong acids burn 
and destroy the tissues with which they come in contact, produc- 
ing swelling, redness, pain and tenderness. Hot metals when 
brought in contact with the eyelids, either produce a blister with 
swelling, redness and pain, or the parts are carbonized at the point 
of contact between the lid and the heated metal, with a surround- 
ing area of inflammation, pain and tenderness: in addition photo- 



84 



INJURIES INVOLVING THE EYELIDS. 



phobia follows all burns and scalds involving the lids. If the burn 
or scald injures the eyeball, complications involving this part en- 
sue, signs and symptoms of which are described under Conjunc- 
tivitis and Ulcers of the Cornea and Sclerotic Coat. 

DIFFERENTIAL DIAGNOSIS: Blepharitis Marginalis 
(Tinea Tarsi) is a chronic pustular inflammation of the edges of 
the eyelids which may be found in adults and which may be 
claimed as due to a burn or scald. This disease is always bilateral, 
occurs in individuals whose occupation exposes them to dust 
and irritating vapors and results in thickening of the edges of the 
lids with loss of the lashes. It should not be mistaken for an ac- 
cident. 

Herpes in this situation may sometimes be said to be caused 




Fig. 7. — Blepharitis marginalis. (Haab). 



by a scald, but a history of having suffered from the same disease 
at a previous time w'ould serve to eliminate this afifection wdien 
claimed as the result of an accident. 

COMPLICATIONS follow severe burns and scalds of the 
eyelids when the eyeball is involved, and these are described under 
disease and injuries of the Cornea and Sclerotic Coat. 

TOTAL DISABILITY in all classes of risks lasts from i to 

3 weeks when the burn or scald has not involved the eyes and is 
only moderately severe. When severe, this disability lasts from 

4 to 8 weeks, and may still be prolonged the same length of time 
if an operation is required for replacing a part of the lid which 
may have been destroyed by the accident. 

PARTIAL DISABILITY follows total in anv class of risks 



ULCERS OF THE CORNEA AND SCLEROTIC COAT. 85 

when the oceupation requires much use of the eyes and lasts from 
I to 3 weeks. Individuals insured under a lower classification 
seldom deserve any partial disability. 

EFFECTS : When the burn or scald has been slight and 
superficial tissue only is destroyed, the resulting scar is imper- 
ceptible. If sufhcient tissue is lost to cause an operation for its 
replacement, the scar is permanent and deformity is more or less 
prominent, depending on the situation of the injury, its extent and 
the success of the surgical operation for its repair. Individuals 
who have suffered from burns or scald of the eyelids which have 
not involved the eyes, are unimpaired for all kinds of insurance. 



PART IV 

CORNEA AND SCLERA 

ULCERS OF THE CORNEA AND SCLEROTIC COAT 





INFORMATION : Ulcers involving the cornea and sclerotic 
coat are frequently seen, are more common in the aged, and are 
due to a number of causes. Small for- _.__, 

► eign bodies which are blown into the 
eyes and remain there for some time 
may cause simple ulcers to form. Ul- 
cers are also the result of a great 
many other causes, and when an in- 
dividual claims disability from an ul- 
cer due to an injury, it is necessary 
that close attention be given to the 
claim and positive history of an acci- 
dent be secured. 

SIGNS AND SYMPTOMS: 
When an ulcer of the cornea or 
sclerotic coat results from the irrita- 

Ition caused by ^ foreign body, there 
is a distinct and well remembered 
history of some particle getting into 
the eye and causing pain and lachrymation which has persist Ovl 
for several davs or more, and has tinallv caused a j-ilivsician 
: 



\ 



S. — Infected ulcer of the 
with hypopyon — hypop- 
on-keratitis. (De SchweinitzV 



Fig. 
>inea. 



86 INJURIES INVOLVING THE CORNEA AND SCLERA 

to be called on when the foreign body is removed. At this time 
there is a circumscribed congestion of the eye with a sUght 
contraction of the pupil. The base of the ulcer has a gray- 
ish floor and presents a slight scooped-out appearance. SHght or 
severe pain is present with lachrymation, blepharospasm and pho- 
tophobia. Ulcers due to disease do not have this history. If an 
individual carries a general health policy, the cause of tlie ulcer 
is unimportant. 

DIFFERENTIAL DIAGNOSIS : Simple or Non-Suppurat- 
ing Ulcers may be due to conjunctivitis, exhausting fevers, im- 
paired nutrition or to a disease or injury involving the ophthalmic 
branch of the fifth nerve. These ulcers so closely resemble those 
caused by injury that a differential diagnosis is only made from 
a previous histor}^ and condition of the claimant. 

Herpetic Ulcers sometimes result when Herpes Zoster of the 
ophthalmic division of the fifth nerve exists, and these begin by a 
number of small vesicles forming on the cornea, then coalescing, 
and an ulcer results. Severe neuralgic pain accompanies this form 
of ulceration and slight anesthesia of the cornea may be present. 

Simple Keratitis, which has been existmg for some time, may 
cause ulcers of the cornea. These ulcers have a tendency to 
spread, some are easily controlled, while others are almost incur- 
able. They exist with or without suppuration. 

PJilyctenular Keratitis is characterized by small ulcers which 
begin by a grayish elevation and usually accompany phlyctenular 

conjunctivitis. These points coa- 
lesce, and as a larger surface be- 
comes aftected, leashes of vessels 
form between the ulcers until the 
whole cornea may be covered by a 
network of blood vessels. These 
points of ulceration are extremely 
painful and cause photophobia of a 
9.— Phlyctenular conjunc- marked deoTcc. The discharp-e 

(De Schweinitz). ^ . ^. 

which comes from these ulcers uti- 
tates the surrounding parts and causes a burning pain. When this 
form is situated on the conjunctiva the duration is short, lasting 
from one to two weeks; when on the cornea they last much 
longer. 

Syphilitic Ulcers may be present on the conjunctiva, and, if 




CONJUNCTIVITIS 87 

found, there is usually a history of this disease existing, and this 
serves to make the diagnosis clear. 

COMPLICATIONS: The different forms of conjunctivitis 
may exist with or complicate an ulcer of the cornea or conjunctiva. 

TOTAL DISABILITY following an ulcer which is caused 
by a foreign body in the eye, in all classes of risks generally lasts 
from I to 2 or 3 weeks, sometimes from 3 to 6 or 8 weeks may 
be necessary before the disability is ended, this depending on the 
depth of the ulcer, its situation and the physical condition of the 
individual, together with the treatment. Ulcers which are caused 
by disease usually require a longer time for healing than those 
resulting from an accident, and this time depends on the kind of 
an ulcer, the physical condition of the individual and the treat- 
ment. 

PARTIAL DISABILITY may sometimes be necessary in 
preferred risks who have suffered from_ an ulcer due to an accident, 
and lasts from i to 3 or 4 weeks, depending on the amount of 
work required of the eyes, the length of previous total disabihty 
and the physical condition of the individual. This disability is not 
deserved in ordinary risks, unless the occupation requires con- 
stant use of the eyes, when the above time would usually be suffi- 
cient. 

EFFECTS : Small ulcers of the cornea which leave little, if 
any opacity, cause no permanent defect of the sight; larger ulcers 
which are followed by so much opacity of the cornea that the sight 
is interfered with, produce impaired risks for accident insurance 
unless the opacity becomes absorbed — which it does to a certain 
degree in some cases. Ulcers not affecting the conjunctiva and 
resulting from accidents, cause no impairment for life, accident or 
health insurance. 

CONJUNCTIVITIS 

INFORMATION: Conjunctivitis or inflammation of the 
conjunctiva of the eye can be due to a number of causes. It may 
be accidental in origin when a foreign body gets into the eye and 
sets up an irritation, when the conjunctiva is burnt by acids, 
quicklime or any other agent that will produce these injuries, and 
also from cuts, lacerations and punctured wounds. Conjunctivitis 
in many cases is not due to an accident, but is caused by disease, 
and if so caused an accident itisurance policy would not cover dis- 



88 INJURIES INVOLVING THE CORNEA AND SCLERA. 

ability arising from this condition, but a health or general disabil- 
ity policy would pay indemnity for the length of time the indi- 
vidual was prevented from resuming the occupation. 

SIGNS AND SYMPTOMS depend on the cause of the in- 
flammation. When the conjunctivitis is due to an injury, there 
is a history of such with evidence of the accident. The conjunctiva 
may be cut, torn or burnt, and these signs are apparent when the 
proper kind of light is used for their detection; in addition there 
is tumefaction of the membrane which is red and injected and ac- 
companied by a watery discharge. If the surface of the conjunc- 
tiva has been ruptured, bleeding occurs. When the inflammation 
is the result of a disease there is no specific spot which marks the 
beginning of the inflammation as would occur following an injury, 
the other signs and symptoms are practically the same, photopho- 
bia being present in all cases of this inflammation. A number of 
cases of conjunctivitis are accompanied or complicated with ulcers. 
For the signs and symptoms of which see description of Ulcers of 
the Cornea and Sclerotic Coat. 

DIFFERENTIAL DIAGNOSIS : Catarrhal Conjunctivitis 
or ''pink eye" is an epidemic inflammation of the conjunctiva in 
which both eyes are generally affected, first one and then the 
other. In this inflammation the individual complains of a smart- 
ing sensation, itching, slight pain and mild photophobia with in- 
creased lachrymation. The conjunctiva of the ball and lids- is 
edematous and red, while the papilla are enlarged and prominent. 
These cases almost always have a history of the individual being 
in contact or knowing some one recovering from a similar con- 
dition, and occur more frequently in the spring and fall, lasting 
from seven to fourteen da3^s. 

Gonorrheal Conjunctivitis is an acute, severe and destructive 
inflammation of the conjunctiva which is caused by a specific germ, 
the gonococcus, which is present in the discharge from the eye. 
This disease is usually transferred by the fingers to the eyes and 
runs a very rapid course, developing within a few hours from the 
time infection occurs, and at first the signs and symptoms are 
those of a simple catarrhal conjunctivitis. They increase, how- 
ever, with great rapidity, and within twenty-four hours a healthy 
eye becomes edematous, swollen and inflamed with a thick puru- 
lent discharge, followed in a short time by ulcers in one or more 
places. This disease is so rapid in its course that the eye may 
be destroved within two to four davs and such a condition never 



*i 



PLATE I 



S' 



'n 




Fig-. 1. — Acute Catarrhal Conjunctivitis. 



% 



Fig. 2. — Purulent Conjunctivitis. 







Fig-. 3.— Acute Trachomato\is Conjunctivitis (ThcobaldV 



1 



CONJUNCTIVITIS. 8» 

results from an accident. Accident or disability policies do not 
always pay indemnity when the disability is caused by this dis- 
ease — which is venereal in origin. 

Granular or Follicular Conjtmctivitis (Trachoma) is an acute^ 
infectious inflammation of the conjunctiva, characterized by thick- 
ening and vascularity of the membrane under which is found 
translucent granular masses. This disease is usually found in emi- 
grants or foreigners, is chronic in its course and would hardly be 
alleged as the cause of disability. 

Phlyctenular Conjimctiz'itis is an inflammation which generally 
occurs in individuals who are debilitated by improper food, expo- 
sure, etc. It is recognized by the appearance of one or more 
grayish red elevations which are capped by small vesicles and 
which rupture and form ulcers. There may be severe pain, pho- 
tophobia and lachrymation. 

Diphtheritic Conjunctivitis is sometimes seen and is character- 
ized by a croupous exudation which is adherent to the conjunc- 
tiva. It usually occurs during the course of diphtheria and can 
be easily diagnosed. 

TOTAL DISABILITY from a simple conjunctivitis which 
has been caused by a small foreign body getting into the eye and 
not compHcated with an ulcer, usually lasts about i week in all 
classes of risks. When the conjunctivitis is the result of a more 
severe injury to the cornea or conjunctiva, and this injury is fol- 
lowed by an ulcer, total disability in all classes of risks lasts from 
2 to 4 or 6 weeks. If the inflammation is a catarrhal conjunctivitis 
occurring in one eye and then after three or four days transfer- 
ring itself to the other eye, total disability usually lasts from lo 
to 14 days. If the inflammation is confined to one eye only, t 
week of this disability is generally sufficient. Gonorrheal conjunc- 
tivitis produces total disability for an uncertain period, depending 
on the virulence of the infection and resulting damage to the eye: 
it may cause disability of from i to 2 or 3 months, almost always 
terminating in the loss of sight in the affected eye. Phlyctenular 
conjunctivitis causes total disability, according to the situation of 
the vesicles. If on the conjunctiva, this disability is short and lasts 
from I to 2 weeks; if on the cornea, it niay require from 2 to 3 
weeks. On account of this disease being more or less chronic, 
great care must be exercised in ascertaining if it existed before 
the policy was taken out. 

PARTIAL DISABILITY is not often denKuuled in conjunc- 



90 INJURIES INVOLVING THE EARS 

tivitis unless the inflammation has been of long duration and the 
individual is one whose occupation requires frequent use of the 
eyes, when from 2 to 4 or 6 weeks may be demanded. This dis- 
ability is not deserved by ordinary risks unless the occupation 
exacts considerable use of the eyes. 

EFFECTS: Simple conjunctivitis as the result of a foreign 
body in the eye does not impair the risk for any form of policy. 
When' the conjunctivitis is severe and results in an ulcer, and this 
ulcer is situated on the cornea, there may be a resulting opacity 
that will interfere w^th the sight; in which event each particular 
case must be considered by itself. An attack of conjunctivitis 
which is followed by an ulcer, even though severe and more or 
less of the sight has been impaired, does not prevent an individual 
from securing a life or health policy. 



PART V 

EARS 

INJURIES OF THE AURICLE 

INFORMATION : The auricle or that part of the ear which 
projects from the head may be injured in a number of ways. These 
injuries, when produced accidentally, seldom cause total disability 
unless the individual is following an occupation which requires a 
constant use of an apparatus to his ear. Telephone operators, 
stock brokers wdio answer the 'phones in such offices, and others, 
may be totally disabled from an injury to this part of the body. 
This part of the ear may also be frozen, w^ien both ears are usually 
in the same condition and total disabiHty would result and persist 
for a longer time for those w^hose occupation requires constant 
use of the ears than where the duties do not frequently require 
them to be pressed against instruments. 

SIGNS AND SYMPTOMS: When the auricle is injured 
by an abrasion, contusion, incision, laceration, punctured wound, 
burn or scald, the signs and symptoms are such as would follow 
these injuries to any other part of the body, and are plainly evi- 
dent. When the accident causes a rupture of the membrana 
tympani there is bleeding from this part, and danger of an infec- 



INJURIES OF THE AURICLES 



91 




tion involving the middle ear is present. If the ears are frost- 
bitten they become red and swollen, painful, rigid and without 
sensation. When the circula- 
tion is re-established in a frozen 
ear, there is burning and itching 
which persists for some days, 
and is followed by peeling of 
the skin of the ears. 

COMPLICATIONS: Hem- 
^atoma Anris is not uncommon in 
the insane, and is usually -due 
to a blow over the ear, al- 
though it may occur spontane- 
ously. It is a blood tumor sit- 
uated between the cartilage and 
perichondrium on the anterior 
surface of the auricle. If this 
swelling is due to an accident, 
other evidence of the injury is 
usually apparent and a history 
of the accident is easily ob- 
tained, together with reports of 
witnesses. 

TOTAL DISABILITY in preferred risks whose occupation 
requires the use of an instrument of any sort in contact with the 
■ear, depends on the degree of injury, and an ordinary abrasion 
or small incision will usually cause total disability to last from i to 
3 days. If the auricle is badly lacerated, punctured or severely 
burned, individuals as above described require from i to 2 weeks 
of total disability. Ordinary risks are entitled to 2 to 7 days of 
total disability only, when a severe injury involves these parts. 
Frost-bitten ears seldom produce enough discomfort to cause 
disability, but individuals will sometimes refuse to resume their 
occupation while the ears are swollen or bandaged, when i 
week of total disability may be allowed if a general health or dis- 
ability policy is carried and other conditions are complied with. 

PARTIAL DISABILITY is sometimes demanded by risks 
of all classes wdien a more or less severe injury of the oar has oc- 
curred. It is questionable if this disability should l>e allowed in 
any case, and if permitted i week would appear ample. 

EFFECTS: After recoverv from an accident to the auricle, a 



Fig. 
lowins 



10. — Perichondritis of auricle fol- 
freezing. (Keen). 



92 



INJURIES INVOLVING THE EARS. 



more or less noticeable scar results or this part of the ear may 
be deformed, depending on the character and extent of the in- 
jury. Individuals who have suffered from such an injury arid re- 
covery has been complete, are insurable for any kind of a policy. 

ABSCESS OF THE MIDDLE EAR 

INFORMATION : AMienever the middle ear becomes in- 
fected, it is generally by way of the eustachian tube and an acute 




Fig. 11. — OPERATION FOR ACUTE MASTOIDITIS FOL- 
LOWING INFECTION FROM MIDDLE EAR. (Keen). 
The entire pneumatic structure of the mastoid has been 
broken down. The tip of the mastoid has been removed, 
exposing the posterior belly of the digastric muscle. The 
sigmoid groove lodging the lateral sinus is well shown. The 
zygomatic cells have also been obliterated and a portion 
of the posterior wall of the bony meatus has been taken 
away. The deepest portion of the bony cavity leads 
directly to the aditus ad antrum. (Author's dissection.) 



abscess results. If the membrana tympani is perforated acci- 
dentally, the infection can enter from that point and the resulting 



ABSCESS OF THE MIDDLE EAR. 93 

disability is covered by an accident policy. Abscess of the ear 
not due to an accidental injury, but resulting in disability is cov- 
ered by a, general health or disability policy and indemnity is pay- 
able under such conditions. Sometimes these policies only pay 
indemnity during house confinement, but as an abscess in this sit- 
uation usually demands confinement for a certain time and the in- 
dividual receives indemnity according to the terms of the policy. 
Individuals suffering from an abscess of the middle ear are in 
danger of having this inflammation extend and involve the brain, 
when the resulting condition assumes a grave aspect. 

SIGNS AND SYMPTOMS : An acute abscess of the middle 
ear is often said to be due to colds, but as the mucous membrane 
of the naso-pharynx is congested and infected with germs, these 
gain entrance to the eustachian tube and travel to the middle ear 
and cause an abscess, when there is pain of a throbbing nature, 
increased temperature, inability to sleep or lie on the affected side, 
and if left alone the abscess evacuates itself through the drum of 
the ear when immediate relief is obtained. 

TOTAL DISABILITY usually lasts from i to 2 weeks in 
all classes of risks, depending on the time when the abscess is 
opened; if opened early this disability is shorter. In cases with a 
severe inflammation, total disability may last as long as 3 
weeks; this being due to the debilitated condition of the individual 
from loss of sleep and appetite during the acute stages of the 
abscess. 

PARTIAL DISABILITY is not deserved in any class of 
risks following an abscess of the middle ear. 

EFFECTS : Individuals wdio have suffered for the first time 
from an abscess in this situation are insurable for any kind of a 
policy from three to six months after complete recovery, and by 
that is meant the discharge has ceased and the membrane has be- 
come entirely healed. Persons suffering from an abscess of this 
kind are not insurable for a life or health policy as long as the 
discharge persists, and if it is present for a number of months or 
years, they are not considered insurable for either of these policies 
until from three to five years have elapsed after the cessation of 
the discharge. Insurance companies will not accept an individual 
for any kind of a policy, if it is known that a discharge is existing 
from either one of the ears. 



94 



INJURIES INVOLVING THE SKULL 



PART VI 

INJURIES INVOLVING THE SKULL 

FRACTURES 

INFOR]\IATIOX : Fractures of the skull are usually consid- 
ered under two heads, fractures of the vault and fractures of the 
base. Injury to the bones in this situation is caused by falls and 
the head striking a hard substance, the result of blows received in 
personal encounters or from a falling body, and also from a fall 
in which the body alights on the feet or base of the spine. Frac- 
tures of the vault are generally produced by direct force, while 
those of the base of the skull result either from a continuation of 




Fig. 12. — Fracture of occipital bone extending- into the posterior 
fossa. (Eisendrath). 

the fracture as the result of direct force, or by transmitted force 
such as would occur through the spine. Disability which results 
from a fracture of any of the bones of the skull is due to tearing 
and laceration of the brain and its membranes, as an injury which 



FRACTURES OF THE SKULL 9& 

will fracture the skull produces serious injury to its contents. 
Fractures of the base of the skull are more often fatal, for the 
reason that they are usually compound, thus permitting an infec- 
tion of the brain. These fractures are not common in early 
youth, being most frequently seen in adult life. 

SIGNS AND SYMPTOMS: Loss of consciousness follows 
a blow which causes a fracture of the skull, and this may last from 
a few minutes or hours to several days, finally ending in com- 




FIG. 13. — MOST FREQUENT LINES OP FRACTURE OF BASE 

OF SKULL. (Eisendrath). 

The black arrows indicate their direction if they traverse 
further than indicated in the illustration: 1, Fracture of 
anterior fossa; 2, 3, fractures of middle fossa; 4, fracture of 
posterior fossa. 

plete return to consciousness or a semi-comatose condition which 
may persist for some time before consciousness is well established, 
headache, inequality of the pupils of the eyes and cerebral vomit- 
ing. When the fracture involves the base of the skull, there is 
hemorrhage from the nose and ears and a discharge of cerebro- 
spinal fluid in a considerable quantity. Shock is one of the promi- 
nent symptoms of a fracture of the skull and its degree of severity 
depends on the injury which has been sustained by the brain. 



96 INJURIES INVOLVING THE SKULL. 

Evidence of a fracture exists and is ascertained by bimanual pal- 
pation which may disclose a depression in the skull. A cracked- 
pot sound is detected under percussion which may sometimes be 
apparent to the individual himself and not to the examining sur- 
g"eon. 

COMPLICATIONS: Infection is the most dangerous and 
frequent complication following a compound fracture of the skull. 
As fractures at the base of the skull are always compound, this 
danger is added in addition to the more serious nature of the 
primary injury. If an infection occurs, meningitis develops and 
death usually ends the case. 

TOTAL DISABILITY in fractures of the skull depends on 
the severity of the fracture, its location and duration of the period 
of unconsciousness. Preferred risks who suffer from a simple 
fracture of the vault of the skull and the period of unconsciousness 
is short, are totally disabled from 3 to 6 weeks. If the fracture of 
the vault has been more extensive or a fracture of the base occurs 
and unconsciousness persists from one to three or four days, tctcl 
disability usually lasts from 6 to 8 or 12 weeks. In cases of a 
fracture involving either the vault or base of the skull when un- 
consciousness persists from one to two or three weeks, total dis- 
ability generally lasts from 3 to 6 months. Ordinary risks suffer- 
ing from a simple fracture of the skull are not totally disabled as 
long as preferred risks, this disability lasting from 2 to 4 weeks. 
In the more serious injuries to the skull occurring in ordinary 
risks, total disability is about the same as that required by pre- 
ferred risks. When the fracture has been compound and infection 
of the brain follows, death frequently ends the case within i 
week after meningitis has developed. If an operation is necessary, 
total disability is not often prolonged thereby. 

PARTIAL DISABILITY is demanded by preferred risks 
following a fracture of the skull and in a smiple fracture with a 
short period of unconsciousness from 3 to 6 weeks are usually 
necessary. V.'hen the fracture has been extensive or compound 
and a considerable period of unconsciousness has followed the in- 
jury, partial disability may be asked, and from 6 to 12 weeks are 
not excessive in these cases. Individuals who are insured under 
the ordinary classification and whose duties do not require brain 
work, are not entitled to any partial disability. 

EFFECTS : Following a fracture of the skull, the effects de- 
pend on the injury to the brain which has occurred at the time 



PUNCTURED WOUNDS OF THE SKULL 



97 



of the accident. Individuals suffering from simple fractures which 
go on to recovery without complications and in which the disabil- 
ity lasts from four to eight wxeks, are insurable for any kind of a 
policy six months after complete recovery. When the accident 
has been more severe and a long period of unconsciousness en- 
sued, either with or without an operation, such individuals are not 
insurable for any kind of a policy until from three to five years 
have elapsed after the date of the accident. Fractures of the skull 
which cause a serious injury to the brain may result in impairment 
of brain activity in the individual, and this may persist for some 
months or years before recovery is complete. 

PUNCTURED WOUNDS OF THE SKULL 

INFORMATION: Wounds of the skull which enter the 
cranial cavity may be either penetrating wounds or those which 




Fig. 14. — Deformed bullets removed from different parts of the body. 
Shrapnel; B, brass-jacketed Remington; C, Mauser bullets. 
(Keen's Surgery). 



enter the cavity only; or perforating wounds when the instrunicut 
or missile which goes into the cavity, not only enters, but also 
leaves it. These wounds are made by violence and result from 
any pointed instrument entering the brain cavity by force or any 
missile propelled by gunpowder. Penetrating or perforating 
wounds of the skull are always accompanied by a fracture in one 



98 INJURIES INVOLVING THE SKULL 

or more places. When the puncture resuhs from a missile pro- 
pelled by gunpowder, the outer table of the skull is penetrated 
and the inner table is usually splintered, and some of these small 
particles of bone are driven into the brain. If the wound is a 
perforating one, these conditions apply to its point of entrance 
and are reversed at its point of exit. Foreign bodies are generally 
carried into a punctured or penetrating wound and in this situa- 
tion may be lodged inside the skull. Disability following this 
class of wounds results from the injury to the brain and not from 
the fractured bones. Injuries due to punctured wounds of the 
skull produce early death or long periods of disability; therefore, 
an early settlement by an insurance company while advantageous 
to them in a financial way, causes so much dissatisfaction and pos- 
sibly a law suit at a later date, that such settlements are not often 
made until disabihty is ended. 

SIGNS AND SYMPTOMS depend on the severity of the in- 
jury and its cause; shock of a more or less degree is always present 
when the brain suffers an injury of any kind. If the wound is a 
penetrating one and is made by a knife, dagger, etc., there is seen 
the point of entrance, with bleeding and sometimes a part of the 
instrument has been broken off and is found imbedded in the skull. 
When the wound is caused by a gunshot missile, there is a small 
point of entrance through the scalp, evidence of a fractured skull, 
bleeding with a discharge of brain substance, unconsciousness, 
cerebral vomiting, rapid, weak, irregular pulse and generally an 
early death. After an injury of this character to the brain, infec- 
tion frequently follows or an abscess develops, but this latter does 
not occur until at least from two to six weeks after the accident. 

COMPLICATIONS always follow a punctured or perforat- 
ing wound of the skull. 

Infection of the wound edges or of the brain itself is the most 
usual compHcation after the infliction of a penetrating wound of 
the skull. When the wound injures the brain, an inflammation 
of the brain itself or its covering only may be the result. 

Tetanus not uncommonly follows a wound of this kind when 
inflicted by fire-arms, and is more often seen when the wound 
has been produced by the explosion of a blank cartridge held in 
close proximity to the head; in addition to infection by the bacillus 
of tetanus, a septic infection also exists. 

Erysipelas is liable to develop in the scalp when a punctured 
wound of the skull exists. Disability, however, is rarely length- 



PUNCTURED WOUNDS OF THE SKULL 99 

ened by this complication unless the puncture of the skull has 
been very small and minute and has not penetrated the skull, 
when the length of time necessary for recovery of the injury would 
not be as long as that required for recovery following an erysipe- 
latous inflammation of the scalp. 

TOTAL DISABILITY following punctured wounds of the 
skull which do not involve the brain, require from i to 3 weeks 
in all classes of risks. If the wound punctures the skull and 
slightly damages the brain itself and is not followed by infection 
or death, total disability usually lasts from 2 to 3 or 6 weeks. 
When the wound becomes a perforating one, death generally re- 
sults at once or within a few days from the time of infliction. 
Punctured or perforating wounds of the skull which severely 
damage the brain almost invariably cause death, but in rare in- 
stances individuals recover after such injuries. In these cases, 
however, total disability is long and uncertain, often lasting from 
2 to 4 months and sometimes longer. 

PARTIAL DISABILITY follows wounds of the skull which 
injure the brain, and in preferred risks lasts from 3 to 12 weeks 
according to the character of the injury and the exact duties of 
the occupation of the individual. Ordinary risks are not often 
entitled to partial disability following this class of injuries, unless 
the occupation requires more or less brain work. This form of 
disability may be necessary and may run the limit of the policy 
in cases following a punctured or penetrating wound of the skull 
which severely injures the brain and causes total disability to last 
two to three months or more. 

EFFECTS: Penetrating wounds of the skull which cause 
short periods of total disability usually leave no impairment, and 
the individual is insurable for accident, health or life insurance 
from three to six months after complete recovery. When the 
wound has injured the brain or has penetrated it, insurance com- 
panies would hardly issue any form of policy to an individual at 
any time following the injury, unless a number of years have 
elapsed and it is shown that no bad results would likely occur, but 
even in such cases it would be hard to convince a medical director 
that the applicant would be an insurable risk for any kind of a 
policy. 



100 



INJURIES AND DISEASES OF THE BRAIN 



PART VII 

INJURIES AND DISEASES OF THE BRAIN 
ABSCESS OF THE BRAIN 



SYNONYMS: Cerebral abscess; acute encephalitis; sup- 
purative encephalitis. 

INFORMATION : Abscess of the brain may be due to a 
number of causes, the most frequent of which is suppurative 
otitis media, nearly fifty per cent, of the cases resulting from this 
disease. The next in frequency is injury, and this is mostly caused 
by a compound fracture of the skull, although a concussion may 
result in an abscess. General septic diseases, such as cancer, tu- 
berculous masses which caseate and syphilis are some of the other 
causes. When an abscess is the result of an injury, it does not 
develop until at least two or more weeks after the accident and is 
generally situated at or near the site of injury. Abscesses vary 
in size, sometimes only containing a small quantity of pus, at 
other times the abscess may be large and occupy the whole 




1 



FIG. 15. — ABSCESS OF THE RIGHT CEREBELLAR HEMIS- 
PHERE. (Keen). 
Resulting- from a pui-ulent clot in the posterior inferior cerebellar 
artery. The enlargement of the artery by the thrombus is shown 
in the illustration. 



ABSCESS OF THE BRAIN 101 

hemisphere. The right side of the brain is most frequently in- 
volved, and when large a fatal result is almost invariable. 

SIGNS AND SYMPTOMS depend on the situation of the 
pus cavity. A brain abscess usually commences with a chill, cere- 
bral vomiting, malaise and headache. The body temperature is 
normal or sub-normal, while the local temperature is increased, 
the pulse is very slow and anorexia is present. Headache may be 
general or localized, and as the abscess increases and causes pres- 
sure symptoms, there is Cheyne-Stokes respirations with an invol- 
untary discharge of the contents of the bowels and bladder. Epi- 
leptiform convulsions sometimes occur, choked disk may be pres- 
ent, and if in both eyes it is more marked on the side correspond- 
ing to the location of the abscess. The pupil on the same side 
as the lesion is frequently dilated and immovable. The mental 
faculties are dulled and as pressure increases, a comatose condi- 
tion gradually supervenes. Large abscesses cause pain and ten- 
derness on the side of the skull analogous to the location of the 
abscess. 

DIFFERENTIAL DIAGNOSIS : Acute Meningitis and ab- 
scess of the brain are sometimes hard to differentiate, although 
the first usually comes on suddenly and is marked with a chill, 
high fever, rapid pulse, flushed face, photophobia, vertigo, nausea, 
vomiting, delirium and marked rigidity of the cervical muscles. 

Mastoid Disease may sometimes be mistaken for abscess of 
the brain, but this is generally associated with suppurative dis- 
ease of the middle ear and is characterized by pain in the mastoid 
region, with tenderness and swelling. An abscess of the brain 
may result from mastoid disease and the two may exist at the 
same time 

Thrombosis of the Lateral Sinus may occur and become in- 
fected. In these cases there will be sw^elling of the veins of the 
head and face, marked fluctuation of the temperature, rigors, 
general prostration and other signs and symptoms of pyemia. 

A Tumor may be diagnosed as an abscess, but when it is re- 
membered that this is of slow growth and the signs and symptoms 
produced by it are faintly marked at first and gradually beconie 
clearer, and also that tumors rarely occur in the temporo-sphe- 
noidal lobe or in the cerebellum, it will be seen that there are 
some distinctive signs between the two, although they arc tow 
and the diao'nosis is ofteii exceedinolv difficult. 



1U2 INJURIES AND DISEASES OF THE BRAIN 

TOTAL DISABILITY is uncertain in any severe injury to 
the head and it is especially so when an abscess of the brain exists. 
This disability may be short, lasting from i to 2 weeks only, or it 
may be long and require from i to 3 months before recovery 
takes place or death ensues. When the diagnosis of an abscess of 
the brain exists and there is a history of a severe injury, such as 
a fracture of the skull or a bad concussion, it is best for an insur- 
ance company to effect an advance settlement with an individual 
who may be carrying an accident policy by allowing i to 2 months 
of this disability. Should an adjustment not be secured, the ab- 
scess may terminate in death, and if this occurs within ninety 
days from the date of the accident the company may be liable for 
a death claim for the amount of the policy, and this would be 
much more than if the above time of total disability had been 
paid. Insurance companies do not care to take chances on these 
cases and prefer to make a settlement in advance. When the ab- 
scess is not the result of an accidental injury, the length of total 
disability would be unchanged, although in these cases an ad- 
vance settlement would not be advantageous to the company, 
for the reason that death may terminate the case at any time, 
when apparently it would run indefinitely. Abscess of the brain 
can only be treated successfully by a surgical operation, which 
should be done at once, and when performed generally shortens 
the period of total disability. 

EFFECTS : Individuals who have once suiTered from an ab- 
scess of the brain and recovered, are not insurable for any kind 
of a policy until at least five years have passed without signs or 
symptoms of any kind, and even at this date it is questionable if 
an insurance company would accept such a person, for the reason 
that there may be some mental impairment which would not 
show on an application, but which would nevertheless exist and 
at some future time have an adverse bearing on the risk. 



■CONCUSSION OF THE BRAIN 

INFORMATION: Concussion of the brain is the result 
any blow to the head which produces a jarring, tearing or lacera 
tion of the fine vessels and nerves of the brain. It may also result 
from indirect force following a fall upon the buttocks or feet. A 
concussion may be so slight as to produce no perceptible signs 
and symptoms, excepting slight headache, or it may be so severe 
that unconsciousness results and persists for days or even weeks. 



a- 1 



CONCUSSION OF THE BRAIN 103 

Concussion of the brain when sustained while the individual is 
intoxicated or under the influence of liquor — according to the 
wording of the policy — precludes obtaining indemnity for injuries 
occurring under these conditions. 

SIGNS AND SYMPTOMS : If the blow has been slight, the 
individual may or may not fall, and this is followed by nausea, 
sometimes vomiting and a feeling of weakness which quickly dis- 
appears. If the injury has been severe, unconsciousness comes 
on at once, with relaxed and flaccid muscles, shallow respirations, 
depression of the heart with a feeble, irregular pulse and a sub- 
normal temperature; no general paralysis exists, but control of 
the sphincter muscle of the bladder and rectum is lost, allowing 
the urine and feces to be passed involuntarily. As the individual 
reacts, cerebral vomiting usually occurs, consciousness gradually 
returns, the pulse becomes stronger and the temperature is 
slightly elevated. This reaction may not take place, when the 
comatose condition may exist for some days or even weeks; this 
depending on the severity of the blow to the skull. This uncon- 
scious condition may slowly disappear, to be followed by a condi- 
tion of semi-consciousness which gradually ceases as the brain 
clears up. Cases in which unconsciousness has lasted from four 
to six weeks or longer have recovered after long periods of total 
disability. 

DIFFERENTIAL DIAGNOSIS: Alcoholic Coma is often 
seen in an intoxicated individual and is sometimes complicated 
with coma resulting from a concussion, but an insurance examiner 
would rarely see a case under these circumstances. 

Coma due to apoplexy may sometimes be seen and claimed as 
the result of a blow to the head. In cases of apoplexy, the pupils 
are uninfluenced by light, relaxation of the muscular system exists 
and voluntary movements are abolished on the paralyzed side. 
The eyes in many cases deviate toward the affected side of the 
brain and paralysis more or less extensive is always in evidence. 

Uremic Coma is sometimes claimed as the result of an acci- 
dent. In this condition there is albumin in the urine, a persistent 
sub-normal temperature, while edema of the legs and convulsions 
occur. 

Coma from other causes may be claimed as due to an acci- 
dent, but the differential diagnosis is easily made; these conditions 
not lasting any length of time. Coma as the result of the above 
described causes are practically the only ones which persist for 



104 INJURIES AND DISEASES OF THE BRAIN 

any length of time and which may be confounded with coma fol- 
lowing an accidental injury. 

COMPLICATIONS: An Abscess often follows a fracture of 
the skull or concussion of the brain and doe§ not develop until 
at least two wrecks after the injury has been sustained. It may, 
however, not show itself until weeks or months after an accident, 
and in some cases abscess of the brain has been said to develop a 
number of years after the injury was inflicted. 

Insanity or incomplete return of the functions of the brain 
may result from a concussion. This condition is usually tem- 
porary, although it may become permanent and require confine- 
ment under restraint. 

TOTAL DISABILITY following the above injuries is most 
uncertain. When the concussion has been slight and the period 
of unconsciousness following the injury has been short, preferred 
risks require from i to 2 weeks of this disability. If the period of 
unconsciousness lasts from one to three or five days, total dis- 
ability in the same class of risks may persist from 4 to 6 or 8 
weeks, — if no complications arise. Ordinary risks under the 
same conditions usually demand i week and 2 to 4 weeks re- 
spectively. Preferred risks who suffer from a concussion of the 
brain followed by unconsciousness lasting from one to two or 
three weeks are usually totally disabled from 2 to 4 or 6 months. 
Ordinary risks require from i to 3 months under the same con- 
dition. 

PARTIAL DISABILITY follows total and is payable to pre- 
ferred risks and those of the ordinary class whose duties require 
more or less mental work. This time may be from 3 to 12 weeks, 
depending on the severity of the primary injury, the resulting 
period of unconsciousness, the physical condition of the individual 
and the exact duties' of the occupation. 

EFFECTS : Insurance companies do not care to issue poli- 
cies to those having suffered from a concussion of the brain in 
which unconsciousness has lasted from one to three days or longer, 
unless a period of from three to five years has elapsed after the 
accident and no evidence of the injury or any change in disposi- 
tion has existed during that time. Individuals w^ho have suf- 
fered from a severe concussion in which total disability has lasted 
from two to six months or more, would hardly be considered as 
insurable risks for any kind of a policy, until from five to eight 
years have elapsed after the accident. 



i 



CHAPTER VI 

INJURIES AND DISLOCATIONS INVOLVING THE JOINTS 
AND BONES OF THE FACE 

DISLOCATION OF THE TEMPORO-MAXILLARY 
ARTICULATION 

INFORMATION : Unilateral or bilateral dislocations of the 
lower jaw occur, the latter being the more common. These dis- 
locations are most frequently seen in women and are caused by 
over distension of the mouth, as in yawning. In the anterior 
form of dislocation, the condyle of the lower jaw is pushed for- 
ward and rests on the eminentia articularis of the temporal bone. 




Fig. 16. — Bilateral anterior dislocation of the 
lower jaw with depressed chin, rigid lower jaw, 
open mouth, drawn cheeks. (Scudder). 

Sometimes these luxations are produced accidentally, when a 
blow is received on the jaw while the mouth is ]xirtly open. Un- 

105 



106 



INJURIES OF THE JOINTS AND BONES OF THE FACE 



less a dislocation of the jaw has a history and evidence of an ex- 
ternal injury from a blow, it is almost always due to over-disten- 
tion and is not properly accidental in origin, and the resulting 
disability, if any, should not be covered by an accident policy. 

SIGNS AND SYMPTOMS depend on the kind of disloca- 
tion present. When bilateral, the mouth is open and fixed in this 
position. The condyles are in front of their usual position and 
posterior to them is a depression which can be readily demon- 




Fig. 17. — Lateral view, same as Fig. 16 with 
rigidity of lower jaw muscles. (Scudder). 

strated by pressure of the finger tips. Saliva flows from the 
mouth, swallowing and speech are difficult and severe pain may 
be present. If a dislocation is unilateral only, one condyle is 
out of position, the lower jaw is not so rigidly fixed in extension 
and there is some movement in the sound articulation. 

TOTAL DISABILITY for dislocations of the lower jaw 
should not be allowed for more than from i to 2 or 3 days, for 
the reason that the dislocation is easily reduced and when the jaw 
is again in position disability is ended. There are exceptions, 
however, which require total disability of from 2 to 3 weeks and 
these occur in preferred risks when the occupation requires con- 
stant use of the mouth and vocal organs, such as singing, teaching, 
public speaking, etc. 

PARTIAL DISABILITY is not payable in any case follow- 
ing an injury of this character. 

EFFECTS : Dislocations of the jaw^ readily recur and in per- 



FRACTURE OF THE NASAL BONES 



1U7 



sons with such a history an accident poHcy should contain a 
waiver which eHminates indemnity for disabihty due to this cause. 
With this waiver on an accident pohcy, individuals are insurable 
for life, accident or health insurance without regard to the history 
of previous dislocations. 

FRACTURE OF THE NASAL BONES 

INFORMATION: A fracture of one or both nasal bones is 
due to direct violence, the break usually involving the lower third 
of the bone and is the result of 
this part of the face coming in 
violent contact with a hard sub- 
stance, as may occur in falls or 
when a blow is received from a 
clenched fist. In the latter case, 
an accident policy would not 
cover the ensuing disability un- 
less the injury was the result of 
an unexpected attack by robbers, 
thugs, etc. 

SIGNS AND SYMPTOMS 
are pain, dizziness, sometimes 
nausea, flattening of the nose 
which may be pushed to one side, 
hemorrhage from the nostrils 
and emphysema of the face and 
eyelids which may follow the 
forcing of air into the cellular 

tissue. Crepitus can sometimes be felt when the fractured 
ends of the bones are moved one upon the other. Hemorrhage is 
often profuse in these injuries and causes difficulty in breathing, 
but is soon checked and is not followed by a discharge of cerebro- 
spinal fluid, as in cases of fractures at the base of the skull. 

COMPLICATIONS : Fractures of the nasal bones may be 
compound, the fractured ends protruding externally or internally. 
When the ends of the bones lacerate the mucous membrane of the 
nose, a resulting infection can occur which may end in septic 
meningitis. If the blow has been a severe one, the cribriform 
plate of the ethmoid may be involved; in which case dangerous 
complications involving the brain often arise. Cerebral concus- 
sion may follow these fractures, and when present is duo to the 




. / 



Fig. IS 
(Scudder). 



-Fracture of nasal bones. 



108 



INJURIES OF THE JOINTS AND BONES OF THE FACE 



violence of the blow producing the primary injury. If this com- 
plication ensues, the length of disability, etc., is found described 
under Concussion of the Brain. 




Fig. 19. — A^'idening 'jl i:--, 

fracture of the nasal bones. (.Keen). 



TOTAL DISABILITY following these fractures depends 
on the individual and the occupation. Preferred risks such as 
clerks in department stores, office help, and those whose duties 
require contact with people are totally disabled from i to 2 weeks. 
Ordinary, or preferred risks whose duties are other than the 
above, usually require from 2 to 5 days only. If the fracture has 
been compound externally and much laceration of the skin exists, 
total disability in preferred risks is increased 7 to 10 days. 

PARTIAL DISABILITY following a simple fracture of one 
or both nasal bones should not be allowed. 

EFFECTS : When the bones are properly set and retained 
in place, there is no resulting deformity. The location of the frac- 
ture or other injuries may make the retention of these bones in 
proper position a difficult matter. In such cases more or less de- 
formity results even after the most careful treatment. An indi- 



FRACTURE OF THE MALAR BONES 109 

vidual who is suffering from a fracture of these bones without 
any compHcation, is insurable for any kind of a pohcy from three 
to four months after the date of the accident. If a concussion of 
the brain occurs or any other compHcation is present, the insur- 
abiHty is determined by the compHcation and not by the injury. 

FRACTURE OF THE MALAR BONES 

INFORMATION: The malar bones are situated on each 
side of the face and form the centre of a convex surface, conse- 




FIG. 20. — FRACTURE OF MALAR BONE. (Eisendrath). 
A frequent seat of fracture of the malar bone alons the 
lines shown, namely, at its junction with the superior maxilla 
and the zygomatic process of the temporal bone. The arrows 
show the direction in which the fragments composed of the 
entire malar bone are dislocated. 



quently a fracture of these bones does not often occur unless it 
is the result of violent, direct force, when one of the processes of 
the bone is usually involved, and in addition concussion of the 
brain may follow from the force of the blow which produces a 
fracture. Other bones of the face are frequently injured when the 
malar bone is accidentallv fractured. 



110 INJURIES OF THE JOINTS AND BONES OF THE FACE 

SIGNS AND SYAIPTOMS are pain when masticating food, 
swelling of the face, depression over the fractured bone or pro- 
cess, with discoloration, and sometimes crepitation can be elicited 
by pressure of this bone against its surrounding articulations. 
When a fracture of the orbital process of the bone occurs, a sub- 
conjunctival hemorrhage may result. 

COMPLICATIONS : Concussion of the Brain may be present 
as the result of a blow which fractures this bone, but unless the 
concussion is severe, disability is not prolonged by this complica- 
tion. 

Fracture of the Superior Maxillary usually exists in conjunction 
with fractures of the malar bone. When they occur, total dis- 
ability is not often prolonged beyond the period required for 
fractures in the malar bone to become united, unless a compound 
fracture of the superior maxillary exists, when disabiHty is pro- 
longed beyond the usual time. 

TOTAL DISABILITY: Preferred risks who suffer from an 
uncomplicated fracture of this bone usually require from i to 2 
weeks of total disability; this time being necessar}^ on account of 
the contused condition of the soft tissues around the bone. Pre- 
ferred risks who are not brought in contact with people generally 
demand from 3 to 7 days of total disability. Slight concussion 
of the brain or a fracture of the superior maxillary bone in con- 
junction with this injury, requires from 2 to 4 weeks of total dis- 
ability in preferred risks. Uncomplicated cases of fractures of the 
malar bone occurring in ordinary risks seldom ask for more than 
from I to 2 weeks of total disability. Compound fractures of the 
bone in preferred risks increase total disabihty from 7 to 10 
days, when no brain complications are present. 

PARTIAL DISABILITY in preferred risks is frequently de- 
manded, and from i to 3 weeks may be allowed. Ordinary risks 
are not entitled to any partial disability. 

EFFECTS: Uncomplicated fractures of the malar bone 
cause a slight flattening on the injured side of the face which is 
hardly noticeable. AMien the orbital plate is fractured and sHghtly 
displaced, more or less protrusion of the eyeball on the affected 
side may result. Individuals suffering from this injury which has 
not been complicated by concussion of the brain are insurable for 
any kind of a policy from two to three months after the date of 
accident, — provided no permanent injury to the eye has followed. 



FRACTURE OP THE SUPERIOR MAXILLARY 111 

FRACTURE OF THE SUPERIOR MAXILLARY 

INFORMATION: Fractures of this bone are usually due 
to direct violence or by transmitted force from blows on the chin; 
sometimes the alveolar process is broken by the extraction of a 
tooth, but in such cases an accident policy is not intended to cover 
the disability. On account of the position of this bone, violent 
force is necessary to produce a fracture, and when this occurs it 
is frequently complicated by fractures of adjoining bones or con- 
cussion of the brain. The fracture is often a compound com- 
minuted one. 

SIGNS AND SYMPTOMS are severe pain which is worse 
when the jaws are closed tightly, great swelling and discoloration 
of the face, inabiHty to masticate food, irregularity in the line of 
the teeth of the upper jaw on the affected side, and when the 
antrum is broken in, there is a depression over this part. Emphy- 
sema of the face sometimes follows, and when this is seen it is due 
to a rupture of the mucous membrane which permits air to be 
forced into the cellular tissue. Injury of the infraorbital nerve 
which emerges through the infraorbital foramen may occur, when 
numbness and anesthesia of the part of the face supplied by it 
will be present. 

COMPLICATIONS : Secondary Hemorrhage' may result 
when branches of the external maxillary artery have been injured, 
and if this comphcation arises danger to life is present, although 
disability is not prolonged. 

Concitssion of the brain may complicate a blow of sufficient 
force necessary for a fracture of this bone. If the con- 
cussion is slight, disability is not prolonged, but if severe total 
and partial disability may be greatly increased by this complica- 
tion. 

Compound or Comminuted Fractures may become infected and 
greatly prolong disability. This is especially true if the antrum 
is opened and infection follows in this situation. 

TOTAL DISABILITY lasts from 3 to 6 weeks in preferred 
risks when the duties of the occupation require singing or con- 
stant talking. In some classes when the duties require the use of 
the hands and brain, such as office work, etc., this disability gene- 
rally persists for 2 to 3 weeks only. Ordinary risks suffering from 
such a fracture without complications usually require from 3 to 4 
weeks of total disability. Compound fractures of this bone are 



112 INJURIES OF THE JOINTS AND BONES OF THE FACE 

mostly through the mucous membrane, and in such cases disabil- 
ity is not prolonged by this complication. When the external 
surface is involved, total disability is increased from 7 to 10 
days in preferred risks. Complications may arise and prolong the 
disability according to the lengtli of time required by the com- 
plication for recovery. 

PARTIAL DISABILITY is sometimes payable to preferred 
risks suffering from the above fracture, when the duties of the 
occupation demand much use of the voice, when from i to 3 
weeks are generally allowed. Ordinary risks are not entitled to 
any partial disability. 

EFFECTS : This bone is so well supported by its neighbors 
that very little displacement occurs after a fracture, and, therefore, 
deformity is slight. This shows mostly by an unevenness in the 
line of the teeth and may result in digestive disturbances, on ac- 
count of inability to properly masticate food or the loss of one 
or more teeth at the time of the accident. If a fracture at the base 
of the skull or a concussion of the brain does not complicate this 
injury, the party is insurable for any form of insurance from six 
to nine months after the date of accident. 

FRACTURE OF THE INFERIOR MAXILLARY 

INFORMATION: Fractures of the inferior maxillary may 
result from direct force when the jaw is brought in violent contact 
with a hard substance, as in falling or when the body is in an up- 
right position and the jaw is struck. If the fracture occurs as the 
result of a personal encounter, the individual being struck by a 
clenched fist, an accident policy does not cover the disability; un- 
less the injured party has been attacked without cause and is pro- 
tecting himself. Fractures of this bone usually occur between 
the symphysis and the canine tooth, although the ramus may be 
broken at some part. The inferior maxillary is frequently frac- 
tured and the mucous membrane torn in the majority of cases, 
thus producing compound fractures. 

SIGNS AND SYMPTOMS are unnatural mobility between 
the two sides of the lower jaw with crepitation on movement, 
pain, much swelling and discoloration of the skin with swelling 
and bleeding of the gums and the constant dribbling of saliva; 
deformity also exists, the teeth are not on an even plane, one or 
two at or near the fracture being loosened. After several days 



FRACTURE OF THE INFERIOR MAXILLARY 113 

the glands under the jaw enlarge and a foul odor is present, this 
being due to the decomposition of blood in the mouth. 




Fig'. 21. — Fracture of the lower jaw, showing loss 
of alinemient of teeth. (Scudder). 

COMPLICATIONS: Infection usually occurs on account of 
the ruptured mucous membrane and suppuration may persist and 
cause necrosis of the bone of the jaw, thus greatly prolonging dis- 
ability. Digestive disorders and diarrhea follow from inability of 
the individual to properly masticate food and also from the swal- 
lowing of blood and infected discharges from the opening in the 
gums, but these latter complications seldom prolong disability. 

TOTAL DISABILITY: Preferred risks sufifering from a 
fracture of the inferior maxillary and who require constant use 
of the voice in singing or talking are totally disabled from 4 to 
6 weeks. In the same class of risks when the occupation is not as 
above, from 3 to 4 weeks of this disability are generally considered 
equitable; this time being necessary on account of the bandages 
which must be worn and which prevent the individual from fol- 
lowing his occupation. Ordinary risks demand from 3 to 5 weeks 
of this disability. The inferior maxillary seldom presents a com- 
pound fracture externally, but when such a condition exists, total 
disability is not often increased. Complications do not often pro- 
8 



114 INJURIES OF THE JOINTS AND BONES OF THE FACE 

long total disability, for the reason that as soon as union is com- 
plete between the two fragments the individual can return to his 
occupation, even though suffering from a slight necrosis of the 
bone or digestive disorders. 

PARTIAL DISABILITY is payable in addition to the above 
total and lasts from i to 2 weeks in preferred risks. Ordinary 
risks are not entitled to any partial disability. If necrosis of the 
jaw ensues, this form of disability may be necessary and may last 
from 3 to 6 or 8 weeks. If intestinal troubles follow, partial dis- 
ability is sometimes payable, allowing from i to 3 weeks, accord- 
ing to the severity of this complication. 

EFFECTS : Fractures of this bone do not always unite per- 
fectly, when there is more or less deformity not noticeable from 
the external surface, but which prevents the proper mastication of 
solid foods and may cause chronic indigestion to follow. Unless 
this condition ensues, there would be no impairment of any kind 
and the individual is insurable for any form of a policy three 
months after the date of accident. 



CHAPTER VII 

INJURIES TO THE NECK INCLUDING THE LARYNX 
AND TRACHEA 

PART I 

ABRASIONS AND CONTUSIONS OF THE NECK 

INFORMATION: These injuries occur to the neck acci- 
dentally or by intent and are produced by contact with hard sub- 
stances. Abrasions are not very frequent, while contusions of 
the neck are often seen and are usually due to blows received in 
personal encounters. Hard blows to the neck may cause a con- 
tusion that will end in unconsciousness or even death. The 
parotid or submaxillary gland, the hyoid bone or the cartilage of 
the larynx are sometimes injured as the result of a contusion, 
when disability is greatly prolonged. If disability results from a 
contusion involving the neck and the injury has been received 
while the claimant was under the influence of liquor or in an 
ordinary fight, indemnity will not often be paid by an insurance 
company, as the policy usually excepts such conditions. 

SIGNS AND SYMPTOMS: Abrasions of the neck produce 
the same signs and symptoms as do abrasions of any part of the 
body and are readily diagnosed; they generally heal without any 
complications and no disability results. Contusions to the neck, 
hov/ever, and especially severe ones, cause swelling and discolora- 
tion. Sometimes there is a fracture of the hyoid bone or the 
cartilage of the larynx, when there may be emphysema of the 
neck and chest or edema of the larynx may become so marked 
that death ensues. Hemorrhage into the larynx if in sufificient 
quantity will produce asphyxiation. Contusions to this part of 
the body can injure either one of the glands on the side of the 
neck and cause an abscess to develop, and this will be attended by 
the usual signs and symptoms. ^Pain is always present after a 
blow to the neck, swallowing is difficult, and if the swelHng is 

115 



116 INJURIES INVOLVING THE NECK 

sufficient there may be impairment of hearing on the injured side; 
breathing may also be affected by pressure on the trachea. 

DIFFERENTIAL DIAGNOSIS: Parotitis or Mumps is 
sometimes claimed as a contusion to the neck. This disease is of 
rather sudden onset beginning with a chill followed by fever from 
1 00° to 103° F, headache, increased pulse rate and swelling of the 
parotid gland with stiffness of the neck. This swelling lasts from 
six to seven days, when it subsides, or the gland of the opposite 
side is involved and goes through the same process. In three 
per cent, of the cases of mumps, mammary glands, ovaries and 
the testes are involved, and when this involvement occurs it is 
sufficient evidence that the swelling of the gland is not due to a 
contusion, but to a well defined disease. 

Tuberculous Adenitis is a specific infection of the glands of the 
neck by the tubercle bacillus. This first causes a sweUing of the 
glands on the side of the neck accompanied by redness, induration 
and fever, and later the formation of pus which is evacuated by 
nature or through an incision. An individual who is tuberculous or 
who has suffered from a swelling of these glands without suppura- 
tion, may have an inflammation set up by a blow to the neck and 
this go on to abscess formation. Such a condition would be hard 
to properly diagnose, and if there were well marked signs and 
symptoms of a blow, an insurance company would probably have 
to pay indemnity for the resulting disability, even though the sup- 
puration was due to a tuberculous infection. 

Tumors of the neck can exist and when a blow is received 
in this situation the swelling may be claimed to be due to the 
injury. These tumors are of slow growth, movable, painless and 
usually encapsulated. If there is any suspicion that the swelling 
is due to a tumor or other cause, even though there may be dis- 
coloration and evidence of a blow, the diagnosis can be properly 
made by waiting vmtil the discoloration disappears, when the 
swelling will also go if due to a contusion; if a tumor, it remains. 

Thyroid Gland: Swelling of this gland or goitre is usually 
seen in women and would hardly be mistaken as a swelling due 
to a blow. This gland may enlarge, however, as the result of an 
injur3^ in which case a history of an accident with discoloration 
would be ascertained. 

COMPLICATIONS : Torticollis or Wry-neck usually involves 
one side of the neck only and results mainly from a, contraction 
of the sterno-cleido-mastoid muscle. Occasionallv this condition 



ABRASIONS AND CONTUSIONS OF THE NECK 



117 



is acute and is the result of colds or blows to this part of the body. 
When it has been present a long time, there is an atrophy of the 




Fig. 22. — Front view left sided tor- 
ticollis. (Keen) 



Fig-. 23. — Back view left sided tor- 
ticollis. (Keen). 



muscles on the opposite side of the face and neck. Acute cases 
are accompanied by pain and swelling, in addition to the contrac- 
tion of the muscle which produces this condition. 

Emphysema occurs after a blow^ to the neck which has been 
sufficient to rupture the mucous membrane of the trachea, when 
air is diffused in the cellular tissue, causing swelling and crepita- 
tion under pressure. 

Fracture of the Hyoid Bone rarely results from a severe abra- 
sion or contusion of the neck. If this occurs, see description of 
Injuries of the Larynx and Trachea. 

Erysipelas may complicate any abrasion of the neck, appear- 
ing from two to seven days after the injury has been sustained. 
If this disease follow^s an abrasion which would cause little, if any, 
disability, an insurance company would hardly pay indemnity un- 
der an accident policy for the disability caused by the disease, as it 
would be impossible to say if the erysipelas was contracted at or 
before the time the abrasion was sustained. For description of 
the duration of this disease, see Erysipelas under Diseases of the 
Skin. 

Suppurating Parotiditis: A contusioii of the nock may be 
sufficiently severe to injure the parotid or submaxillary glands and 
cause an abscess to form; if this occurs and a fistula result"^, heal- 



118 INJURIES INVOLVING THE NECK 

ing is greatly prolonged. Should either of these glands suppurate 
as the result of a blow in which there is no question about the 
injury being inflicted, an insurance company would probably be 
liable for the length of disabihty caused by the blow and the re- 
sulting abscess. 

TOTAL DISABILITY: Preferred risks suffering from an 
abrasion of the neck which is uncomplicated, are not entitled to 
any total disabihty. If erysipelas develops, it is questionable if 
the company is liable for indemnity during the period of disability 
caused by this disease. All classes of risks suffering from a con- 
tusion of the neck are entitled to little, if any, total disability, un- 
less the injury has been so severe as to cause one or more com- 
plications to arise, when the length of disability is determined ac- 
cording to the complication, and the question of liability must also 
be settled at that time. Torticollis following a contusion of the 
neck may require total disability of i week in preferred risks 
as the price of a release, although an individual suffering from 
this condition is not totally disabled. If the parotid or sub- 
maxillary glands suppurate as the result of an injury, total dis- 
ability may last from i to 2 or 3 weeks, but as this disability would 
not immediately follow the blow, it is questionable if an insurance 
company would recognize liability, probably claiming that the 
abscess was not caused by the blow, for the reason that it would 
not appear until some time had elapsed. Emphysema following 
a contusion of the neck would cause total disability of from 3 to 
7 days in all classes of risks. A tuberculous abscess of the glands 
of the neck when claimed to be due to a contusion may cause 
total disability for an indefinite period, and an insurance com- 
pany would not likely assume liability for indemnity under such 
a condition, even though there might be a history of a blow of 
more or less severity. 

PARTIAL DISABILITY is not payable to any class of 
risks following an abrasion or contusion of the neck. 

EFFECTS : Simple abrasions or contusions to this part of 
the body which cause no complications, result in no impairment 
of the risk, the individual being insurable for any kind of a policy 
from one to two months after the date of injury. If a complica- 
tion arises, the effects on the insurability of the risk must be con- 
sidered according to the complication which was present. 



INCISIONS AND LACERATIONS OF THE NECK 119 

INCISIONS AND LACERATIONS OF THE NECK 

INFORMATION: Incised or lacerated wounds of the neck 
may be superficial or deep, and any wound which goes below the 
deep fascia may be considered more than superficial. These 
wounds are produced by any sharp or blunt instrument which 
cuts or lacerates the soft tissues of the neck and may be accidental 
in origin or by intent. Suicides generally attack the neck for this 
purpose with a sharp instrument, the cut being directly across the 
neck in front and on the sides; therefore any incised or lacerated 
wound that has apparently been produced by a sharp instrument 
should be carefully investigated and the fact determined whether 
the wound was self-inflicted or accidental. The class of wounds 
which go deeper than the deep fascia usually involve some of the 
important blood vessels and nerves of the body; or the trachea or 
esophagus is injured. 

SIGNS AND SYMPTOMS : Evidence of an incised or lacer- 
ated wound is apparent to the eye. There is hemorrhage which 
may be arterial or venous in character, depending on whether a 
large artery or vein has been severed. If the w^ound is deep and 
a part of the muscles of the neck are separated, partial control of 
the head is lost. When a wound involves the trachea, there is an 
escape of air through the incision; if the esophagus is open, swal- 
lowing is impossible and there is vomiting of blood which finds 
its way into the stomach. The character of the weapon which 
causes the wound should be ascertained; if this is known it is pos- 
sible in many cases to approximate the damage inflicted. 

COMPLICATIONS depend on the location and depth of the 
wound. Superficial wounds may be followed by infection or ery- 
sipelas may develop. Deep wounds which have injured some of 
the important contents of the neck may cause complications ac- 
cording to the part injured, — if death is not produced at once by 
the incision or laceration. 

An Abscess sometimes follows and is situated beneath the 
deep fascia of the neck when the wound has penetrated beyond 
this point. In such cases it may be difficult to diagnose the con- 
dition on account of the pus being so deeply seated, btit the pos- 
sibility of it traveling downward into the thorax must be remem- 
bered. 



120 INJURIES INVOLVING THE NECK 

Bronchitis and Broncho-Pncnnwnia may develop after such an 
injury and be due to the inhalation of cold air or septic matter 
taken into the lungs when breathing. Disability is prolonged by 
such a complication and indemnity under an accident policy would 
probably only be paid for the time required by the wounds for 
complete healing, provided the injury was not self-inflicted. 

Emphysema may complicate deep wounds which involve the 
trachea and becomes so extensive as to affect the whole neck and 
chest. 

TOTAL DISABILITY following superficial incised or lacer- 
ated wounds should not be allowed to any class of risks unless the 
cuts or lacerations are very extensive, when from 3 to 7 days may 
sometimes be necessary. Deep incisions or lacerations cause total 
disability according to the location, depth and the character of the 
underlying tissue which is injured. Deep cuts which may or may 
not become infected and which do not involve the trachea or 
esophagus require from i to 3 weeks of total disability in all 
classes of risks, and this time is usually necessary on account of 
the shock from loss of blood which follows at the time the injury 
was inflicted. If the wound involves the trachea or esophagus, an 
operation may be necessary for suturing these parts together; 
in which case total disability in all classes of risks will last from 
3 to 6 weeks. 

PARTIAL DISABILITY is hardly allowable to any class of 
risks following incisions or lacerations to the neck, unless the in- 
dividual has suffered the loss of a large amount of blood and total 
disability is comparatively short, when from i to 2 weeks of par- 
tial disability may be allowed to preferred risks. 

EFFECTS: A more or less prominent scar which can be 
covered in some cases always results from an incised or lacerated 
wound. The prominence of this scar depends on its position, 
length, depth, and if followed by an infection or not. When the 
trachea or esophagus has been injured, there may be permanent 
difficulty in breathing or swallowing. Individuals suffering from 
this class of wounds which are self-inflicted are not insurable and 
will not be insured by any insurance company for any kind of a 
policy if a history of the case is known. AAHien the wounds have 
been sustained accidentally and no resulting deformity is pres- 
ent, individuals are insurable for any kind of a policy from one to 
two months after complete recovery. 



PUNCTURED WOUNDS OF THE NECK 121 

PUNCTURED WOUNDS OF THE NECK 

INFORMATION : Punctured or perforating wounds of the 
neck are not frequent, but when they do occur they are generally 
extremely dangerous, causing death at once; or they are slight 
and cause practically no damage to the important contents of the 
neck. These wounds are produced by missiles propelled by gun- 
powder or other foreign bodies which may come violently in con- 
tact with the soft tissues of the neck, and by long, sharp-pointed 
instruments such as stilettos and knife blades. 

SIGNS AND SYMPTOMS depend on the character of the 
instrument which produces the injury and also the location and 
parts involved. Bullet wounds, which are perforating, produce 
an opening at the point of entrance which is smaller than the mis- 
sile itself, while the point of exit is larger and surrounded by 
lacerated tissue. Punctured wounds from, daggers are evident 
and in addition are compHcated by an incision which occurs at 
the time the instrument is forced into the neck or when it is 
withdrawn. In every case there is evidence of the wound, hemor- 
rhage which may be slight or severe, pain, shock, and if the 
trachea or esophagus has been punctured, breathing through the 
opening or vomiting of blood which has been swallowed occurs. 

COMPLICATIONS: Infection almost invariably follows a 
punctured or perforating wound to this part of the body, thus 
prolonging disabihty. 

Tetanus may develop, and this is especially true if the wound 
has been caused by the discharge of fire-arms which have been 
held close to the body. 

Emphysema of the cellular tissues of the neck and front of the 
chest sometimes occurs when the trachea has been punctured. 

Aspiration Pneumonia may follow a wound which injures the 
trachea. If this disease compHcates the injury, disability is 
greatly prolonged and in some cases death may result on account 
of the complication and not from the accident. Under these cir- 
cumstances an insurance company would be liable for indemnity 
covering the time required for recovery from the accident; and if 
death from pneumonia occurs it could not be claimed as acci- 
dental. 

TOTAL DISABILITY following punctured or perforating 
wounds of the neck which do not injure any of the important parts 
cause from 3 to 7 days of total disability in preferred risk§. Ordi- 



122 INJURIES INVOLVING THE NECK 

nary risks demand from 2 to 4 days under the same circum- 
stances. When a punctured wound of the neck severs any of the 
important blood vessels or nerves and is followed by infection, all 
classes of risks are totally disabled from i to 2 or 3 weeks. If the 
trachae or esophagus has been injured and an operation is neces- 
sary, total disability may last from 3 to 6 weeks in all classes. 
Punctured wounds which sever any of the deep blood vessels of 
the neck and cause the individual to become almost exsan- 
guinated, require from 3 to 6 weeks of total disability; this time 
being necessary on account of the great loss of blood. 

PARTIAL DISABILITY is not deserved in any class of 
risks following punctured wounds of the neck, except in pre- 
ferred risks when the hemorrhage has been severe and a short 
period of total disability only has been suffered; in these cases 
from I to 2 weeks may sometimes be necessary. 

EFFECTS : A scar always results from this class of wounds, 
but generally it is not prominent, and if so situated may be hidden 
by the beard or clothing. If the wound heals properly and no 
difficulty in breathing or swallowing remains, an individual is in- 
surable for any kind of a policy from one to two months after 
healing is complete; provided the injury has been sustained acci- 
dentally. Persons suffering from punctured or perforating 
wounds which have been self-inflicted, are not insurable for any 
kind of a policy during the remainder of their lives. 

BURNS AND SCALDS OF THE NECK 

INFORMATION: The neck, together with the face, is I 
often involved in these injuries which may be caused by contact 
with boiling liquids, steam, flames, superheated metals or acids. 
All degrees of burns and scalds to the neck are met with, from., 
the most superficial, which cause no disability, to severe injuries | 
causing prolonged disability and resulting in permanent scars and 
deformity. 

SIGNS AND SYMPTOMS: Following a scald from hot 
liquids or steam, there is redness, swelling and the formation of 
bhsters. If the scald is more severe, in addition to the blister the 
flesh is literally cooked and a slough forms and is thrown off. 
When the injury is a burn from hot metals or acids, the same signs 
are seen unless the burn is verv severe when the flesh is carbon- 



BURNS AND SCALDS OF THE NECK 123 

ized. Acid burns are usually in streaks and spots and only the 
superficial surfaces are involved. There is pain, tenderness, more 
or less nervous shock, some rigidity of the neck and in many 
cases infection with a discharge of pus. 

DIFFERENTIAL DIAGNOSIS : Pemphigus in some stages 
presents the appearance of a superficial scald, but as this disease 
is chronic and is most common on the limbs and the blebs occur 
in crops and on persons who are debilitated, there is not much 
chance of making an error in the diagnosis. 

COMPLICATIONS that follow any wound which breaks the 
surface of the skin are liable to occur when a burn or scald is sus- 
tained. 

TOTAL DISABILITY in preferred risks lasts from 5 to 10 
days when the burn or scald is moderately severe and occupies 
an area several inches in diameter; if an infection complicates the 
injury, total disability may be prolonged i to 2 weeks. If the 
burn or scald is severe and destroys not only a large area of skin, 
but also some of the deeper tissues, total disability in preferred 
risks lasts from 3 to 5 weeks. Ordinary risks do not often demand 
total disability for superficial burns or scalds, but when the burn 
has been deep and severe it may be necessary to pay from 2 to 3 or 
4 weeks. 

PARTIAL DISABILITY is sometimes payable to preferred 
risks when the period of total disability has been short; in such 
cases from i to 2 weeks are usually demanded. Ordinary risks 
are not entitled to any partial disability unless the burn or scald 
has been very severe and the period of total disabihty is greatly 
prolonged, when from i to 2 or 3 weeks are sometimes necessary 
under these circumstances and the occupation permits a part of 
the work being performed. 

EFFECTS : Scars always follow burns or scalds of the neck 
which are more than superficial in depth. These scars may be so 
situated that they can be covered up and produce no disfigure- 
ment. When the injury has been severe and a large scar results, 
it almost invariably contracts, drawing the skin and producing 
deformity not only of the neck, but in many cases involving 
the face. Individuals who have suffered from burns or scalds of 
the neck which do not injure any of the large vessels, nerves, the 
larynx, trachea or esophagus are insurable for any kind of a policy 
from one to three months after complete recovery. 



124 



INJURIES INVOLVING THE NECK 



n 



PART II 

INJURIES TO THE LARYNX AND TRACHEA 



J 



IXFORMATIOX : The larynx and trachea being superfi- 
cially situated are subject to injuries which may be external or in- 
ternal in origin. Injuries from external causes are usually incised 
wounds which are suicidal or homicidal in intent, contusions, 
punctured wounds, and in rare cases fracture of the cartilages of 
the larynx or trachea. AMien the larynx is injured from the in- 
side, it may be due to the inhalation of steam or the entrance of 
caustic fluids when an attempt is made to swallow them, and for- 
eign bodies which cut, lacerate or contuse the internal surfaces of 
these parts. 

SIGNS AND SYMPTOMS following injuries to the larynx 
depend on the character of the accident. Blows to the neck which 




Fig. 24. — X-ray of foreign body in Trachea. (Eisendrath). 



INJURIES TO THE LARYNX AND TRACHEA 125 

injure the larynx are followed by pain, localized swelling and 
ecchvmosis with a chano-e in the tone of the voice, and if the 
mucous membrane has been lacerated, slight hemoptysis occurs, 
but it may be so severe as to cause death within a short time. If 
fractures of the larynx exist, they are generally found involving 
the thyroid and cricoid cartilages when pain, inability to speak, 
cough with bloody, frothy expectoration and dyspnea are present 
and later edema and discoloration of all the tissues surrounding 
the injury. If the wound has been an incision there is pain, hemor- 
rhage, an escape of air through the cut and in som.e cases emphy- 
sema of the surrounding tissue with cough and expectoration of 
bloody frothy mucus, \\n.ien the injury involves the inside of the 
trachea, foreign bodies produce cough, severe spasmodic dyspnea, 
expectoration, pain, edema and in many cases a fatal result follows 
unless tracheotomy is performed immediately. Burns or scalds 
usually produce edematous laryngitis, and this is characterized by 
pain, dyspnea, rapid and extensive edema and often early death. 
If this does not occur, sloughing of the damaged tissue follows and 
later scars which cicatrize and produce strictures, cause great 
difhculty in breathing and speaking. 

DIFFERENTIAL DIAGNOSIS: Incisions involving the 
larynx and trachea when suicidal in intent are said to be across 
the front of the neck and consist of short cuts which may be suffi- 
ciently deep to sever the esophagus. The position of incised 
wounds of the neck involving the larynx and trachea is almost 
sufBcient (according to some authorities) for a diagnosis as to the 
manner of production, whether intentional or accidental. 

COMPLICATIONS: Edema of the larynx is the most fre- 
quent complication following any kind of injury which involves 
this part of the body. It is due to an infiltration of fluid into the 
sub-mucous or connective tissue and may occur with great rapid- 
ity, destroying life by suffocation, unless an operation is quickly 
performed. 

Abscess of the Larynx is most common following a disease of 
the cartilages, but has been known to occur when an injury to 
this part of the body has been sustained. It is diagnosed by means 
of a laryngoscope. 

Ulcers of tJie Larynx sometimes follow when a foreign body 
has become imbedded in the mucous membrane and remains there 
for some time. These ulcers, however, are generally produced by 
other causes and are found under a lar)-ngoscopic examination. 



126 INJURIES INVOLVING THE NECK 

TOTAL DISABILITY following accidental injuries to the 
larynx or trachea depends on the cause, extent of the injury and 
the occupation. Severe contusions may result in death in from i 
to 2 or 3 days, if not, total disability may last from i to 2 weeks 
unless a tracheotomy has been performed, when the disability is 
increased to 2 to 4 weeks. If a fracture of the hyoid bone or 
some part of the cartilage exists, total disability in all classes of 
risks may last from 2 to 4 weeks. Individuals without regard to 
occupation, suffering from an incision or laceration are totally 
disabled from 3 to 6 weeks and sometimes longer. If the injury 
is sustained to the mucous membrane, this disability is very un- 
certain, lasting from i to 2 weeks in moderately severe burns from 
steam or caustics to 4 to 6 or 8 weeks in severe ones. 

PARTIAL DISABILITY is not often deserved following in- 
juries of the larynx or trachea, for the reason that as soon as an 
individual can resume part of his occupation, he can attend to all 
the duties. 

EFFECTS : Contusions which do not produce death leave 
no permanent defects and the individual is insurable from three 
to six months after the date of the accident, unless the contusion 
has been produced by a self-inflicted attempt at strangulation, 
when such a person would never be insurable for any kind of a 
policy. Incisions or lacerations which penetrate the larynx or 
trachea may result in complete recovery and no permanent defect 
in speech or breathing; such individuals are insurable for any kind 
of a policy from one to two years after complete recovery. If the 
injury leaves a permanent deformity of any kind, the injured party 
is not insurable under any form of policy. Scars result from in- 
cised or lacerated wounds to this part of the body, but as the loca- 
tion is usually below the line of clothing, they are seldorn notice- 
able. Severe injuries to the inside of the larynx or trachea, such 
as burns or scalds, almost invariably result in scars which contract 
and narrow the lumen, this may be so pronounced that difficulty 
in speaking or breathing is present. In such cases, an insurance 
company would not issue any form of policy. 



CHAPTER VIII 

ACCIDENTAL INJURIES INVOLVING THE CHEST, 

ABDOMEN AND BACK WHICH RESULT 

IN DISABILITY 

PART I 

CHEST 
ABRASIONS AND CONTUSIONS 

INFORMATION : Abrasions and contusions of the chest are 
not uncommon. When abrasions occur, usually some other part 
of the body is injured, and if disability ensues, it is almost invari- 
ably caused by the more serious injuries. Contusions of the chest 
may be sustained and result from severe blows, from squeezing 
by railroad cars and other means and by being run over by 
vehicles of all descriptions. When a severe contusion of the chest 
is suffered, the injury may involve the soft tissues only and no 
resulting fracture of any of the bones which enter into its forma- 
tion follow. This is due to the elasticity of the chest walls. The 
contents of the cavity, however, may be badly injured, such as a 
rupture of the heart, pericardium, lung or some other large ves- 
sels contained in the mediastina. Severe pressure of the chest 
walls which will rupture some of the contents of this cavity will 
often produce slight, if any, external evidence of the damage done 
inside. Heavy automobiles passing over persons produce serious 
injury to the contents of the chest, but show little evidence on 
^the outside. 

SIGNS AND SYMPTOMS : Evidence of an abrasion to this 
part of the body is apparent on inspection. Contusions may cause 
swelling, more or less discoloration, tenderness on pressure and 
pain on deep breathing, which is made much worse by coughing 
or sneezing. When the injury causes damage to any of the tho- 
racic viscera, the signs and symptoms are such as would come 

127 



128 INJURIES INVOLVING THE CHEST 

from the organ concerned. A contusion of the lungs causes se- 
vere pain, cough, shght hemoptysis and paroxysmal dyspnea, to 
be followed later by dullness over the injured area, crepitation and 
expectoration of rusty sputum. If the lung is ruptured and col- 
lapsed, there is pain, hemorrhage, severe shock, dullness on per- 
cussion over the fluid and hyperresonance over the air cavity. 
When the heart or pericardium is injured by a contusion, severe 
shock is the most prominent symptom, and is followed either by 
death or a pericarditis. Shock is always a prominent symptom in 
injuries involving these parts and may be nervous in origin or due 
to loss of blood which follows a rupture of some of the blood ves- 
sels or viscera of the chest cavity. Hemorrhage may be slight 
or severe and is sometimes concealed; at other times expectora- 
tion of blood occurs. 

COMPLICATIONS : Fractures of the Sternum, Ribs or Ver- 
tebrce may occur when contusions of the chest are sustained. If 
these complications arise, see description of the complication 
under the proper name. 

Pneumothorax generally results if a fractured rib penetrates 
the lung, when there is complete or partial collapse, indicated by 
bulging of the intercostal spaces, increasing dyspnea, tympanitic 
resonance and absence of breath sounds. 

Hemothorax usually follows when an intercostal artery has 
been wounded and is diagnosed by bulging of the intercostal 
spaces over which dullness exists and rapidly extends, increasing 
dif^culty in breathing and absence of breath sounds over the col- 
lection of blood. 

Empliysema of the chest walls not uncommonly follows when 
the lung has been ruptured, even though a fracture of the ribs 
is not sustained at the time of the accident. 

Pneumonia and Plenrisy sometimes follow severe contusions 
of the chest and may terminate fatally. For description of these 
compHcations see Pneumonia and Pleurisy. 

The Heart or Pericardium may be ruptured when the body has 
been violently squeezed between two movable objects or between ^ 
wheels and the pavement. If the heart is ruptured, death of course 
occurs immediately. If the pericardium is the part injured, shock 
may be so severe as to result in death or a long period of dis- 
ability. 

Rupture and Collapse of the Lungs may follow a severe contu- 
sion, when the period of disability will be uncertain and some 



INCISIONS AND LACERATIONS OF THE CHEST 129 

Other complication, such as pneumonia, pleurisy, abscess or gan- 
grene generally results. 

TOTAL DISABILITY following simple contusions of the 
chest which involve the walls only, produce total disability .of 3 to 
7 days in preferred risks. Ordinary risks seldom demand any 
total disability for this kind of injury unless it has been very se- 
vere, when 3 to 7 days are also necessary. If a contusion of the 
chest produces a jarring or concussion of the contents of the chest 
cavity and no further injury, total disability in all classes of risks 
lasts from i to 3 weeks. More severe contusions result in death 
at once or produce long periods of disability lasting from 4 to 6 
or 8 weeks in all classes of risks. If complications arise after se- 
vere contusions, the length of disability is prolonged according to 
the time required for recovery of the complication. 

PARTIAL DISABILITY is not often demanded, except fol- 
lowing very severe injuries, when the length of time will depend 
on the organ injured and the period of total disability. These 
periods of partial disability, however, are usually long and last 
from 3 to 6 or 8 weeks. 

EFFECTS : Individuals suffering from slight uncomplicated 
contusions of the chest, are insurable for any kind of policy from 
two to three months after the date of accident. If the contusion 
has been severe and some of the organs of the chest cavity have 
been injured, insurability would depend on the character of the 
injury and the resulting period of disability; it being necessary 
also to consider any complications which might arise. Insurance 
companies would hardly grant any form of policy to a person who 
had suffered from a severe contusion of the chest until one to 
three years had passed without any signs or symptoms appearing 
as a result of the injury. 

INCISIONS AND LACERATIONS OF THE CHEST 

INFORMATION : Incised or lacerated wounds of the chest 
wall are produced by sharp or blunt instruments which cut cleanly 
or lacerate the tissue. On account of the formation of the chest, 
these injuries can be superficial only, unless they become penetrat- 
ing or punctured wounds, wdien they are considered under those 
heads. 

SIGNS AND SYMPTOMS: Incised wounds produce exten- 
sive hemorrhage, separation of the wound edges, pain, tender- 



130 INJURIES INVOLVING THE CHEST 



1 



ness and sometimes infection. Lacerated wounds tear and lacerate 
the tissues in a ragged manner, causing some hemorrhage, bruis- 
ing of the parts with discoloration, pain and frequently infection. 

Any Complication that is liable to follow a rupture of the con- 
tinuity of the skin may complicate incised or lacerated wounds of 
the chest. 

TOTAL DISABILITY: Incised wounds of the chest which 
are two or three inches in length and require several stitches, 
usually demand from 3 to 10 days of this disability in preferred 
risks. Ordinary risks under the same condition frequently ask 
for I to 2 weeks. Lacerated wounds of the chest involving a con- 
siderable area and which become infected require from i to 3 
weeks of total disability in all classes of risks. 

PARTIAL DISABILITY is not often deserved by any class 
of risks following an incised or lacerated wound of the chest which 
does not produce injury to any of its contents and should seldom 
be paid. 

EFFECTS : This class of wounds heal and leave a superficial 
scar, but as this is covered by clothing it is not perceptible and 
the risk is insurable for any kind of a policy from one to two 
months after the date of accident. 

PUNCTURED WOUNDS OF THE CHEST 

INFORMATION: AA^ounds of the chest wall that are pro- 
duced by any sharp-pointed instrument may penetrate into this 
cavity or on account of the position in which the instrument is 
held, it may travel a considerable distance under the skin without 
penetrating. Missiles propelled by gunpowder produce punctured 
wounds of the chest, and if the missile goes completely through, 
it becomes a perforating wound. Weapons such as long daggers 
or swords produce perforating wounds of this cavity. These 
wounds are dangerous, according to the position of the organ or 
tissue involved. Punctured or perforated wounds which involve 
the heart are almost invariably fatal at once, although recently 
some cases of punctured wounds of the heart have been success- 
fully treated and recovery has followed. In perforating wounds 
by bullets, the point of entrance is always smaller than the point 
of exit, which is ragged and contused. Punctured wounds by in- 
struments with sharp edges are complicated with an incision which 
is made when the weapon enters or is withdrawn from the chest. 

SIGNS AND SY^^IPTOMS: W^ounds of this kind which do 



I 



PUNCTURED WOUNDS OF THE CHEST 



131 



not enter the chest cavity produce pam, swehing, bleeding, slight 
shock and short periods of disability. If the weapon enters the 
chest cavity and injures the lung, there is evidence of the punc- 
ture externally, pain and hemorrhage which comes from the point 
of entrance with cough and expectoration of blood. When air 
enters the chest through a punctured wound, collapse of the lung 
ensues and a hissing sound as it passes in and out of the chest 
cavity can be heard at the location of the wound; evidence of this 




Fig-. 



-Punctured wounds of the chest and arm by daggei 



(Draper). 



is often seen when the opening is filled with blood and mucus. 
When the heart is injured by any weapon, death usually takes 
place immediately, if not, there is extreme pain in the region of 
the heart followed by rapid and difficult breathing, irregular and 
unsteady pulse, shock, collapse and hemorrhage. Shock is always 
a prominent symptom of penetrating wounds of the chest. 

COMPLICATIONS: Hemothorax is almost invariably 
caused by a punctured or penetrating wound of the chest or a 
fracture of one of the ribs, the broken end of which projects into 
the pleural cavity. This collection of blood often becomes in- 
fected and results in empyema. 

Empyema is the term applied to a collection of pus in the 
chest cavity and frequently follows any wound which ruptures the 
pleura; it is due to an infection which enters the cavity at the time 
the injury occurs or at a later date. 

Pneumonia is a complication following ]nuictured wounds of 



132 



INJURIES INVOLVING THE CHEST 



c 


\ 



the chest or any mechanical injury to the lung which causes a de- 
terioration of the lung tissue and permits the diplococcus of 
pneumonia to find a suitable soil for its propagation. 

Subcutaneous Emphysema 
may be present after a puncture 
of the chest and is generally 
seen occupying an area of sev- 
eral inches around the wound, 
although it may extend and in- 
volve the chest and neck and 
even the wdiole trunk, including 
the head and scalp. 

Pneumocele rarely follows a 
punctured or penetrating wound 
of the chest, although it may be 
present and is due to violent 
spells of coughing which force a 
small part of the lung through 
the wound. 

Ftg. 26.— Emphysema fallowing frac- GafWrCnC of the LUTl^ may 

ture of the ribs on the right side. Note ^ '=' 

the puffiness of the face— the eyes almost OCCUr aS the rCSUlt Of a pUUC- 

closed. (Warren). , 

tured or penetratmg wound, 
fractures of the ribs and sometimes from severe concussion to 
the brain. It is most commonly seen in diseases and is not often 
the result of an accidental injury. 

Abscess of the Limg is sometimes traumatic in origin and may 
follow contusions, fractures of the ribs or sternum or gunshot 
injuries; such a complication greatly prolongs the period of dis- 
ability. 

Pericarditis as the result of injury is rare; when it occurs the 
usual signs and symptoms characteristic of this atTection follow- 
ing a disease are present. This complication results in death in 
the majority of cases and when recovery takes place a long period 
of disability follows. 

Punctures of the Esophagus may complicate this class of 
wounds to the chest. In such cases, vomiting of blood and the 
contents of the stomach, together with the escape of mucus and 
ingesta through the external wound would indicate this complica- 
tion which would greatly prolong disabilit3^ 

Opening in the Diaphragm: Small punctured wounds of the 



PUNCTURED WOUNDS OF THE CHEST 133 

diaphragm usually heal without trouble. Large rents permit the 
abdominal contents to escape into the chest cavity with the danger 
of a resulting strangulated hernia. Such cases require operation, 
and if the complication is not diagnosed early the condition may 
end fatally. If attention is given to this at the time the punctured 
wound occurs, disability is not prolonged. 

TOTAL DISABILITY following punctured wounds of the 
chest depends on the character of the injury and the organ 
wounded. If the puncture involves the chest wall only, total dis- 
ability lasts from 3 to 7 days. Punctured wounds which involve 
the heart usually prove fatal at once or within i to 3 days. If 
death does not follow, total disability may last from 4 to 8 weeks 
and even longer, depending on the location of the wound in the 
heart, the result of an operation if performed, and the physical 
condition and constitution of the individual. Punctured wounds 
of the lungs are generally complicated by an infection and total 
disability lasts from 4 to 8 or 12 weeks; if complications super- 
vene, this disability is prolonged according to the time described 
under the complication. The above time appHes to all classes of 
risks. 

PARTIAL DISABILITY may be necessary following punc- 
tured wounds to the contents of the chest cavity, and in preferred 
risks lasts from 2 to 4 or 6 weeks, depending on the organ injured, 
the strength of the individual and the after treatment. 

EFFECTS : Individuals having suffered from a punctured 
wound of the heart and survived, are not insurable for any kind 
of a poHcy unless from five to ten years have elapsed since the 
date of the accident, when if no signs or symptoms have appeared 
during- that time, the application of the individual may be consid- 
ered after a very careful medical examination. Injuries to the 
lungs which are aggravated by one of the numerous complica- 
tions, would prevent an insurance company accepting any one suf- 
fering from such a condition until at least three to five y^ars had 
passed after complete recovery. It is questionable, even at this 
time, if such risks are insurable for life or health insurance, al- 
though an accident insurance policy could probably be safely is- 
sued. Punctured wounds involving the chest walls only, produce 
no permanent impairment and the individual is insurable as soon 
as recovery is complete, provided the moral hazard is good. 



134 INJURIES INVOLVING THE CHEST 

BURNS AND SCALDS OF CHEST AND ABDOMEN 

INFORAIATION : These injuries to the anterior, lateral and 
posterior walls of the chest and abdomen are usually very severe 
and result from steam, hot fluids, molten metals and acids which 
come in contact with this part of the body and are often confined 
beneath the clothing. These burns or scalds are usually superfi- 
cial in extent, but a large area of surface is frequently involved. 
Molten metals sometimes produce punctured wounds to either 
one of the cavities ; but this form of burn is rarely seen. 

SIGNS AND SYMPTOMS: Shock is the most important 
symptom following a severe burn of the chest, abdomen or back 




1 



Fig-. 27. — Cicatrical contracture from a 
months previously. (Keen). 



■flame burn six 



which destroys a large surface of skin; in addition there is swelling 
of the parts involved, redness, bHsters, pain, tenderness, and in a 
few days suppuration ensues. AMien the burn or scald has been 
severe and destroys some of the tissues, sloughing follows and dis- 
ability is greatly prolonged. 



BURNS AND SCALDS OP THE CHEST AND ABDOMEN 135 

DIFFERENTIAL DIAGNOSIS : It would seem that no 
error in diagnosis should be made when a burn or scald exists of 
sufficient severity to cause disability. Any disease which may re- 
semble superficial scalds would not have the acute signs and symp- 
toms of a severe burn or scald as above indicated. 

COMPLICATIONS : Infection and Sloughing are the most 
frequent complications following a severe injury of this character. 

TOTAL DISABILITY in all classes of risks when a burn 
or scald is superficial and involves an af ea of two to three inches 
in diameter lasts from 3 to 7 days. Preferred risks are totally 
disabled from 2 to 3 weeks, and ordinary risks from 3 to 5 weeks 
in burns or scalds which involve a larger area and are compli- 
cated with infection and sloughing. Such injuries may not be 
healed in the above time, but this disabihty should not last until 
the healing process is entirely completed, the individual being 
able to return to his work when the wound is almost well. Se- 
vere burns which destroy a large area of the surface of the chest, 
abdomen or back, usually require skin grafting before healing is 
complete, and all classes of risks are totally disabled from 4 to 6 
or 8 weeks and sometimes longer, this depending on the rapidity 
with which new skin is formed and the number of skin grafting 
operations necessary for the complete healing of the parts. These 
severe injuries are alw^ays accompanied by shock, and this serves 
to prolong disability. 

PARTIAL DISABILITY is necessary in preferred risks 
who resume their occupation before healing of the destroyed sur- 
face is complete, and lasts from 2 to 4 weeks. Ordinary risks do 
not often return to work until new skin is completely formed and 
they are seldom entitled to any partial disability. Severe burns 
or scalds involving the whole surface of the chest, abdomen or 
back requiring a long period of total disabihty may result in 
greatly prolonged periods of partial disability, sometimes even 
running to the limit of the policy. These cases are exceptional, 
however, and when seen are met with in persons already debili- 
tated from some cause. 

EFFECTS: A scar always results from a burn or scald to 
this part of the body, and if of any depth contraction occurs and 
deformity exists. Injuries that have destroyed a larg'e surface of 
the skin are followed by scars which contract greatly, but on ac- 
count of the parts being covered by clothing, the deformity is not 
apparent, and unless the burn or scald involves tlie nuiscles sur- 



136 



INJURIES INVOLVING THE CHEST 



rounding the arm, shoulder or neck, there is seldom any resulting 
permanent disability. Individuals who have suffered from shght 
or severe burns or scalds of the chest, abdomen or back which 
have not caused any injury to the underlying organs, are insurable 
for any kind of a pohcy from six to twelve months after complete 
recovery, provided no permanent disability exists. 

DISLOCATION OF THE STERNO-CLAVICULAR 
ARTICULATION 

INFORMATION: Dislocations of the sternal end of the 
clavicle are rare, for the reason that the Hgaments surrounding 




Fig. 28. — Forward dislocation of the sternal end 
of the clavicle. (Fowler). 



the inner end of the clavicle are very strong, and in addition there 
is an inter-articular cartilage which serves to bind the inner end 
of the clavicle to the sternum and cartilage of the first rib. Dis- 
placement of the bones forming this articulation is caused by 
falls, in which the shoulder comes in violent contact with the 



DISLOCATION OP THE STERNO-CLAVICULAR ARTICULATION 137 

ground or by transmitted force extending from the hand or elbow 
up through the arm. The dislocation may be forward, backward 
or upward; the first of which is most frequent. 

SIGNS AND SYMPTOMS : When the dislocation has been 
forward the inner end of the clavicle is in front of the sternum^ 
while immediately back of it there is a depression which this end 
of the bone formerly occupied. The shoulder on the injured side 
is lower than usual, and there is locaHzed pain, tenderness and 
inability to use the arm. Dislocations backward and upward are 
very rare and show the end of the bone to have disappeared from 
its normal position, and in its place there is a depression. Pain, 
tenderness and often pressure by the dislocated end of the bone 
on the trachea or great vessels of the neck exists when the dis- 
location is backward and causes dyspnea and redness of the face. 

DIFFERENTIAL DIAGNOSIS : Deformity of the clavicle 
due to rickets usually involves the sternal end, the convex surface 
of the curve is forward and may be claimed as a dislocation, but 
absence of inflammatory signs and symptoms together with a 
fixed position of the bone will serve to make the diagnosis. 

TOTAL DISABILITY in preferred risks lasts from 2 to 4 
weeks, when the occupation requires the use of the arms, such 
as bookkeepers, stenographers, telegraph operators, etc.; in the 
same class, when the occupation consists of office duties and su- 
pervising, this disability lasts from 2 to 5 days longer. Ordinary 
risks are usually totally disabled longer than preferred risks and 
require from 3 to 6 weeks of total disability following any form of 
dislocation of the sternal end of the clavicle. 

PARTIAL DISABILITY of i to 3 weeks is allowable to 
preferred risks whose duties require constant use of the arms ; in 
the same class of individuals when the duties do not require much 
use of the arms and hands and the total disability has been short, 
partial disability may last from 2 to 4 weeks. Ordinary risks are 
not entitled to this form of disability, as they can resume all the 
duties of their occupation when they take up any of them. 

EFFECTS : Dislocations of this joint are prone to recur, 
therefore, an individual who has suffered from this injury is not 
insurable for an accident policy, unless a waiver is placed on it 
eliminating indemnity for such disability. Individuals with a his- 
tory of a dislocated clavicle are insurable for life or healrh insur- 
ance from three to six months after the date of injury, except in 
those rare cases where the dislocation has been backward or up- 



138 INJURIES INVOLVING THE CHEST 

ward and pressure has been severe on the blood vessels and 
nerves of the neck, when an insurance company would hardly, as- 
sume any liability on sucli a risk until all danger from such an 
injury had passed. 

FRACTURE OF THE CLAVICLE 

INFOR]\L-VTIOX : The clavicle is more frequently fractured 
than any other bone of the body, the cause being direct or in- 
direct force, but in rare instances the injury results from violent 
and prolonged contraction of the deltoid and pectoral muscles. 




Fig-. 29. — Comminuted fracture of the left 
clavicle with characteristic attitude and vis- 
ible deformity. (Mixter). 

The bone is most often fractured at its weakest point, which is 
just external of its middle. — at the junction of the larger and 
smaller curves. It is most commonly seen in children, next in 
frequency being young and middle aged adults. Both clavicles 
may be fractured at the same time and this condition is usually 
caused by forcible compression of the shoulders. 

SIGNS AND SYMPTOMS are localized pain, tenderness, 
discoloration, swelling, deformity and preternatural mobihty, with 
loss of function in the arm on the injured side, the shoulder of 
which falls downward, forward and- inward. Individuals suffering 



FRACTURE OF THE CLAVICLE 139 

with this fracture are invariably seen supporting- the arm of the 
injured side by the hand of the opposite side. When both clavicles 
are fractured, marked dyspnea may occur on account of the fall- 
ing forward and downward of the shoulders; this is immediately 
reheved when the individual assumes a recumbent position. 

COMPLICATIONS: Fractures of this bone are usually sim- 
ple, and are uncomplicated; compound, comminuted and multiple 




/ 



^ 



I 



FIG. 80.— X-RAY OF FRACTURE OF CLAVICLE. (Eisendrath i. 
The black arrow points to the seat of fracture. The inner fragment has been 
pulled upward and the outer fragment is displaced behind the inner one. 

fractures may occur, w^hen infection is liable to follow. The ends 
of a simple fracture are wired together sometimes, when the injury 
becomes a compound one through surgical intervention, but dis- 
ability is not prolonged on account of the operation. 

TOTAL DISABILITY: If the clavicle of the right side has 
been fractured, preferred risks such as stenographers and writers 
who require constant use of the right arm are totally disabled 
from 4 to 6 weeks; in the same class of risks, when the left clavicle 
is fractured, total disabilit}^ lasts from i to 3 weeks, and this tinie 
is increased i to 2 weeks if the fracture is compound. Should an 
operation for wiring the ends together l)e performed, total dis- 
ability is prolonged 2 to 3 weeks. Ordinary risks require from 6 
to 8 weeks of total disability for a fracture invoh ing either one 
of the clavicles. If both are iM-oken at I ho same time this dis- 



140 INJURIES INVOLVING THE CHEST 

ability lasts from 6 to 8 weeks. Compound fractures occurring to 
ordinary risks prolong the period of disability i to 3 weeks. 

PARTIAL DISABILITY of i to 2 weeks is payable to pre- 
ferred risks suitering with a fracture of the right clavicle when 
the duties of the occupation require more or less use of the right 
arm. In the same class following fractures of the left clavicle 
this period of disability is usually from 2 to 4 weeks. Ordinary 
risks are not often entitled to any partial disability. 

EFFECTS : Deformity more or less prominent generally 
fohows a fracture in any part of this bone, but no permanent dis- 
ability results. Persons who have suffered from a fracture of one 
or both clavicles are insurable for any kind of insurance from six 
to nine months after the date of accident, provided, of course, 
good union results and there is no impairment of function. 

DISLOCATION AND FRACTURE OF THE STERNUM 

INFORMATION: Dislocations and fractures of this bone 
are extremely rare and w^hen sustained are usually caused by vio- 
lent direct force, such as a heavy weight falling on the body when 
it is in a recumbent position, the passing of heavy vehicles over it. 



Common situation of 
fracture. 




Manubrium. 



Body, 



Ensiiorm process. 



HI 



Fig-. 31. — Sternum of an adult showing separation at junc- 
tion of manubrium and body.*" (Scudder). 



DISLOCATION AND FRACTURE OF THE STERNUM 141 

and by indirect force when the body is violently bent forward or 
backward. These dislocations and fractures are most frequent at 
the junction of the first and second segment of the sternum or 
at the articulation between the manubrium and gladiolus. Such 
injuries between the gladiolus and the ensiform process are very 
rare and need not be considered. Disability is the same following 
either class of injuries, and they are therefore described together. 

SIGNS AND SYMPTOMS: History of the accident must 
always be learned for the purpose of making a proper diagnosis. 
There is usually displacement at the point of injury, swelling, dis- 
coloration and pain which is increased on deep inspiration, cough- 
ing or sneezing. Crepitus may sometimes be elicited by ausculta- 
tion or by means of the hand placed over the fracture or disloca- 
tion. These injuries are almost always accompanied by severe 
internal disturbances and frequently terminate in death. 

DIFFERENTIAL DIAGNOSIS : Dislocations generally oc- 
cur at the junction of the manubrium and gladiolus, and this is 
the point that fractures are also most common, but as the signs 
and symptoms of both are practically the same, it is not difficult 
to make the diagnosis, and there should be no mistake in confus- 
ing this form of injury with any other accident or disease in this 
locality. 

COMPLICATIONS mostly involve the heart or lungs, in 
which case see Contusions or Punctured Wounds of the Chest. 

TOTAL DISABILITY: When the above injury has been 
sustained, death generally ends the case within i to 3 days. If 
this does not occur, total disability may last from 4 to 6 or 8 
weeks in all classes of risks according to the internal complica- 
tions present. Compound fractures of this bone through the 
skin only and not followed by infection do not prolong disability, 
but if infection ensues and an abscess of the mediastinum occurs, 
total disability is greatly prolonged, if death does not take place 
soon after the infection. 

PARTIAL DISABILITY is sometimes claimed by preferred 
risks following this injury, and must be allowed if the work of 
the individual requires much bending or lifting: from 4 to 8 weeks 
may be necessary in these cases. 

EFFECTS : Deformity almost invariably results after a dis- 
location or fracture of the sternum. If the repair has been com- 
plete and no movement exists at the point of injury and no serious 
complications have developed, the individual may be considered 



142 INJURIES INVOLVING THE CHEST 

for any kind of insurance from one to two years after complete 
recovery. 

DISLOCATIONS OF THE COSTAL CARTILAGES 

Dislocations of the cartilages of the ribs are extremely rare 
and may be due to direct or indirect force, the cartilage being 
separated at its sternal end or at its junction with the rib. The 
most common site of these injuries involve the seventh and eighth 
cartilages. x\s these accidents are mostly the result of a crushing 
force, injury to the contents of the chest cavity frequently occurs. 
Signs and symptoms and periods of disability are the same as for 
fractures of the ribs, and for these descriptions see the following 
article on Dislocations and Fractures of the Ribs. 

DISLOCATIONS AND FRACTURES OF THE RIBS 

INFORMATION : Dislocations of the ribs are so seldom 
met with that they scarcely need be considered. They are prac- 
tically the same as fractures of the ribs, with the exception, how- 
ever, that fractures are very frequent. The ribs most frequently 
broken are numbered from the fifth to the ninth inclusive. These 
injuries are more common in men in adult life and are generally 
due to direct force, although sometimes the fracture is caused, 
when the bod}^ is caught and badl}^ squeezed between two hard 
substances. Fractures of these bones may be compound inter- 
nally or externally, usually the former, when the uneven end of 
the rib tears and lacerates the pleura and lung with which it comes 
in contact. 

SIGNS AND SYMPTOMS: Localized pain is present at 
the site of injury, and this is aggravated by movements of the 
chest wall; swelling; discoloration, and wdien the lung has been 
injured, expectoration of bloody, frothy mucus follows. There 
may be a slight deformity and crepitation can sometimes be felt 
or heard over the injury. Emphysema may be present when the 
fracture is compound internally. 

COMPLICATIONS which may follow a dislocation or frac- 
ture of the ribs are described under the description of Contusions 
or Punctured Wounds of the Chest. These complications may 
greatly prolong disability. 

TOTAL DISABILITY following dislocations or fractures 



DISLOCATIONS AND FRACTURES OF THE RIBS 143 

of the ribs depends on the occupation of the injured party. Pre- 
ferred risks whose duties are inside and who are not required to 
do any lifting or reaching, are totahy disabled a short time only, 
from 3 to 7 days in many cases. Other preferred risks, as book- 
keepers, stenographers and office clerks, may require from i to 2 
weeks of total disability. Fractures of the ribs which are com- 
pound externally prolong disability in preferred risks i to 2 
weeks. If the fracture is compound internally in any class and 
one of the complications described under Punctured Wounds of 
the Chest occurs, total disability is controlled by the complication. 
Ordinary risks are prevented from returning to their occupation 
longer than preferred risks, and usually demand from 3 to 5 weeks 
of total disability. If the fracture is compound externally, dis- 
ability in this class is not prolonged beyond the above time. 

PARTIAL DISABILITY in addition to the above total is 
payable to preferred risks when the first disability is short, and 
from 2 to 3 weeks may be allowed. Ordinary risks are not often 
entitled to any partial disability. 

EFFECTS : Fractured ribs usually unite without much de- 
formity and cause no impairment of the risk for any form of in- 
surance, provided no complication involving the heart or lungs 
has occurred following the accident. If any of the internal organs 
of the chest cavity have been injured, it would be necessary that 
each individual case be considered separately. If a compound 
fracture existed and injury to the lung resulted, the individual 
would not be considered insurable for any form of insurance un- 
til at least one year had passed without any symptoms referring 
to the accident having show^n themselves. 



PART II 

INJURIES AND DISEASES OF THE ABDOMEN 

ABRASIONS AND CONTUSIONS 

INFORMATION : Abrasions of the abdomen are generally 
seen when more severe injuries are sustained by the individual, 
and seldom cause any disability. Contusions which involve the 
walls only are usually not severe enough to cause either total or 



144 INJURIES AND DISEASES OF THE ABDOMEN 

partial disability. If a contusion of the abdomen occurs and is 
so severe as to injure any of the contents of this cavity, then total 
or partial disability may follow, and in some cases death ensues. 
Contusions may be caused by violent blows to the abdomen from 
a clenched fist, a kick by another individual or animal, by heavy 
weights falling and striking this part of the body or by vehicles 
passing over it. Such injuries, when severe, involve some of the 
organs of the abdominal cavity, and the resulting disabiHty de- 
pends on»the parts injured. Severe contusions of the abdomen 
may result in hernia, either inguinal or umbilical, when such a 
condition is easily recognized and is fully described under Hernia. 

SIGNS AND SYMPTOMS: Slight blows which do not in- 
jure any of the contents of this cavity may produce naus,ea and 
vomiting with some tenderness on pressure. When the contusion 
has been severe, the signs and symptoms are characteristic of the 
organ injured. If the stomach is ruptured, there may be nausea 
and vomiting, and if a vessel is broken, blood is vomited and 
serious shock ensues, this being followed by peritonitis unless an 
operation is performed immediately. Exceptionally severe blows 
may injure the sympathetic nervous system, causing death at once 
or after twelve to twent3^-four hours. If the bladder or kidneys 
are involved in the injury, there is pain, followed by a discharge 
of bloody urine, and if a rupture of the bladder occurs, the con- 
tents of this cavity are emptied into the abdomen; externally 
there is swelling over the point of injury followed by pain, ten- 
derness and discoloration. Rupture of any of the viscera of the 
abdominal cavity or laceration of the peritoneum is followed by 
distention and rigidity of the abdominal walls and a rapid and 
weak pulse. 

COMPLICATIONS: The Stomach may be ruptured as the 
result of a severe contusion to any part of the abdomen. If this 
complication occurs, death results from septic peritonitis or a sur- 
gical operation is necessary, when the period of total and partial 
disability is greatly prolonged. The liver is frequently ruptured 
in severe injuries of the abdominal cavity resulting from extreme 
pressure. Hemorrhage into the peritoneal cavity, followed by 
peritonitis and operation or death is the usual end of such cases. 
If a fatal termination does not take place, disability is greatly 
prolonged. 

Rupture of the Bladder is most common following punctured 
or penetrating wounds, but is also caused by violent compression 



ABRASIONS AND CONTUSIONS OF THE ABDOMEN 145 

of the abdomen which may be due to the passing of heavy vehicles 
over it. Such cases terminate in celluHtis and sloughing of the 
perineum, resulting in death or a surgical operation for repair of 
the injury, thus prolonging disability. 

Rupture of the Intestines may occur from severe contusions to 
the abdominal wall. Such injuries allow the contents of the in- 
testines to escape into the peritoneal cavity and result in death 
within a short time from shock, hemorrhage or inflammation of 
the peritoneum or require an operation which causes disability 
to be greatly lengthened. 

The Xiphoid cartilage is sometimes injured in a severe con- 
tusion, and if this occurs, — especially in an individual who blows 
a wind instrument, — disability is greatly increased on account of 
the inabihty to inflate and forcibly empty the lungs, this function 
being impaired from the pain which is present when forcible ex- 
piration takes place. 

Injury to some of the other contents of the abdominal cavity 
is possible in conjunction with any of the above injuries or alone; 
and if it occurs an abdominal operation may be necessary to pre- 
vent death; if successful, disability lasts according to the time re- 
quired for recovery of the organ injured. 

TOTAL DISABILITY is not payable to any class of risks 
from an abrasion or contusion of the abdominal wall which is not 
complicated by an injury involving some of the contents. If the 
contusion injures any of the organs of the abdominal cavity by 
concussion and jarring only and does not cause a rupture, from i 
to 3 weeks of total disability are usually sufficient in all classes of 
risks, provided death does not occur within one to three days 
from the date of accident. If a rupture of any of the organs of the 
abdominal cavity is caused by concussion, disability is very un- 
certain, depending on the part injured, the constitution of the in- 
dividual, the physical condition and the treatment. Death may 
occur in these cases at once or within 7 to 10 days as the result of 
peritonitis which supervenes. If life is preserved by an operation, 
total disability lasts from 4 to 6 or 8 weeks after the date of 
operation, provided it is successful and the parts heal without 
any comphcations. 

PARTIAL DISABILITY is sometimes demanded by pre- 
ferred risks following a severe contusion of the abdomen without 
serious injur}^ to its contents, and from i to 2 weeks may be al- 
io 



146 INJURIES AND DISEASES OF THE ABDOMEN 

lowed if the period of total disability has been short. Ordinary 
risks are not entitled to any partial disability. 

EFFECTS : Abrasions and contusions of the abdomen which 
have not caused any serious injury, have no bearing on the in- 
surabihty of a risk for any kind of insurance. Individuals suffer- 
ing from severe contusions which have produced long periods of 
disability or caused a rupture of some of the organs of the ab- 
dominal cavity, are not insurable until one to three years have 
elapsed after complete recovery and no signs or symptoms have 
appeared in the meantime. 

INCISIONS AND LACERATIONS OF THE 
ABDOMINAL WALLS 

INFORMATION: Incised or lacerated wounds of the ab- 
dominal walls are usually complicated with other and more seri- 
ous injuries to some other part of the body. Superficial wounds 
of this character produce little, if any, total disability. Injuries 
that have been caused by sharp or blunt instruments and which 
result in a clean cut wound or a lacerated, contused and torn one, 
are usually severe enough to produce total disability during the 
time required for complete healing. Very deep incised or lacer- 
ated wounds require careful suturing of the parts separated, and 
confinement to bed until the wound is entirely healed, if not, a 
hernia may result. Injuries of this character which penetrate 
into the peritoneal cavity with or without injuring any of the con- 
tents, are described under Ptmctured Wounds of the Abdomen. 

SIGNS AND SYMPTOMS: On infliction there is hemor- 
rhage, pain, separation of the edges in incised wounds and ragged, 
torn edges in lacerated ones. If the peritoneal cavity has been 
opened, a protrusion of some of its contents may occur. Shock 
follows severe incised or lacerated wounds, the severity depending 
on the extent of the injury and the hemorrhage which occurs 
at the time. Abdominal wounds which become infected are fol- 
lowed by pain, tenderness, swelling, redness and suppuration. If 
any of the organs of the abdominal cavity have been injured, signs 
and symptoms referring to the particular part involved are pres- 
ent and are described under Punctured Wounds of the Abdomen. 

COMPLICATIONS: Hernia may occur after a long, deep, 
incised wound of the abdominal cavity which has not been prop- 
erly sutured or supported by an abdominal bandage until the scar 



PUNCTURED WOUNDS OF THE ABDOMEN 147 

becomes strong enough to prevent escape of the contents of the 
abdomen. 

TOTAL DISABILITY in superficial incised or lacerated 
wounds lasts from 2 to 7 days in all classes of risks when the cut 
or laceration occupies a considerable area or there are a number 
of small incisions or lacerations widely separated. If the incision 
or laceration has been deep and severed some of the muscles of 
the abdominal wall, total disability in all classes of risks lasts from 
2 to 3 weeks. If an infection follows in these wounds, this dis- 
ability is prolonged 7 to 10 days. When the incision or laceration 
penetrates into the abdominal cavity and injures some of the con- 
tents, total disability in all classes of risks depends on the organ 
injured and is described under Punctured Wounds of the Ab- 
domen. 

PARTIAL DISABILITY is not deserved in any class of 
risks following superficial incised or lacerated wounds to this part 
of the body. When the incision or laceration has been deep, par- 
tial disability of i to 3 weeks may be necessary in preferred risks 
whose duties require an upright position during the greater part 
of the day. This form of disability is not often demanded by or- 
dinary risks. 

EFFECTS : Deep wounds of this character leave scars, and 
if any of the muscles of the abdominal wall have been severed and 
the ends not properly brought together, a ventral hernia may re- 
sult. One to two months after complete recovery from deep, in- 
cised or lacerated wounds, an individual is insurable for any kind 
of a policy, but good underwriting would require a waiver on an 
accident policy eliminating disability from hernia. 

PUNCTURED WOUNDS OF THE ABDOMEN 

INFORMATION : Punctured wounds of the abdominal wall 
are divided into non-penetrating and penetrating wounds; the 
former of which involve the abdominal walls only and do not pen- 
etrate into the abdominal cavity. Penetrating wounds are those 
which go entirely through the thickness of the walls of the ab- 
domen and enter the peritoneal cavity, either injuring sonic of 
the organs contained therein or rendering infection of this cavity 
possible. Punctured wounds are generally inilictcd by sharp- 
pointed instruments such as nails, pitch forks, knives, or as the 
result of gunshot injuries. Stab wounds may become penetrating 



148 INJURIES AND DISEASES OF THE ABDOMEN 

ones without injuring any of the organs of the abdominal cavity; 
bullets from firearms may also enter this cavity and apparently 
produce no injuries. Penetrating wounds which are received in 
civil life from revolvers, shot guns, etc., usually produce much 
injury to the contents of the cavity, and death rapidly follov^s, 
either from loss of blood or from septic peritonitis which ensues. 
Bullets from high speed, modern rifles using powder which pro- 
duces great velocity, do not cause such serious injuries and re- 
covery follows in many cases. 

SIGNS AND SYMPTOMS depend on the character of the 
wound, whether non-penetrating or penetrating. If the injury in- 
volves the wall of the abdominal cavity only and does not pene- 
trate it, there is apparent the point of entrance from which bleed- 
ing occurs. Pain is complained of and localized tenderness may 
be present together with some shock. If the puncture has been 
made by an instrument of considerable calibre, gapping of the 
wound edges follow^s. Punctured wounds that become penetrat- 
ing ones and cause injury to any of the contents of the abdominal 
cavity, produce signs and symptoms which are referable to the 
organ injured. In addition there is almost invariably a profuse 
hemorrhage with a low tension pulse, severe shock which is in- 
dicated by pallor, sweating, coldness of the extremities, dizziness 
and often unconsciousness. Nausea and vomiting usually occur 
in all penetrating wounds of the abdominal wall. After several 
hours or days, symptoms of peritonitis supervene, such as a rigid, 
swollen, tense abdominal wall, anxious expression of the face, 
rapid feeble pulse, restlessness, vomiting and generally increased 
temperature. Emphysema may be present either in penetrating 
or non-penetrating wounds and is not of much diagnostic import. 

DIFFERENTIAL DIAGNOSIS between non-penetrating 
and penetrating wounds of the abdominal wall is highly important. 
Stab wounds which enter the peritoneal cavity in a straight line 
are easily recognized by a probe or the introduction of any other 
aseptic instrument. AMien the wound has been caused by gunshot 
missiles, it is extremely important that knowledge be gained as 
to whether the bullet penetrated the abdominal cavity or not, and 
the diagnosis of this is sometimes ver}^ difficult. If some part of 
the intestines, the omentum or the contents of the stomach, in- 
testines or bladder escape through the wormd, evidence that it is 
a penetrating one is sufficient, but these do not always occur. Es- 
cape of hydrogen gas through the wound after having been forced 



PUNCTURED WOUNDS OP THE ABDOMEN 149 

into the intestines, would be conclusive proof that the wound 
was not only a penetrating one, but that some part of the in- 
testines were also perforated. Hemorrhage which is contained 
in the abdominal cavity gives rise to well recognized signs of fluid 
in the peritoneal cavity. Blood may be passed per rectum, but 
usually not early enough to be of any diagnostic value. Signs and 
symptoms following injuries to the different organs are described 
under Complications. 

COMPLICATIONS : The Diaphragm may be punctured as a 
complication of any penetrating wound and occasionally the 
jagged end of a fractured rib produces the same result. In such 
cases, if the opening is large enough, some of the contents of the 
abdominal cavity usually pass into the thorax, producing a hernia. 
Cases of puncture of the diaphragm are extremely difficult to 
diagnose and the condition is seldom known until an abdominal 
section is performed or a postmortem is made. 

Stomach Injuries as the result of gunshot and stab wounds are 
not uncommon and often complicate penetrating wounds of the 
abdomen. When the stomach has been perforated, vomiting of 
blood. occurs and sometimes the contents of the stomach pass 
through the wound in the abdominal wall. Perforations of the 
stomach are diagnosed in obscure cases by the use of hydrogen 
gas. 

Wounds of the Liver and Gall-Bladder which occur as the re- 
sult of a punctured wound of the abdominal wall are followed by 
profuse hemorrhage and escape of bile, and unless an abdominal 
operation is performed at once and the wound closed by deep 
sutures, death generally terminates the case in a short time. 

The Pancreas is sometimes injured by bullets or stab wounds, 
but the diagnosis is seldom made until after death ensues or an 
abdominal operation has been performed for the treatment of 
other punctures. 

Punctured Wounds of the Spleen are followed by excessive 
hemorrhage, and as in the case of the liver and pancreas, the diag- 
nosis is not often made unless the abdominal cavity is opened for 
some reason, when the bleeding may be stopped or the entire 
spleen removed if necessary. 

Intestinal Perforations complicating perforating wounds of the 
abdominal wall are extremely difficult to diagnose, unless some 
of the contents of the intestines are discharged through the wound 
or a fecal odor can be determined at the point of perforation. 



150 INJURIES AND DISEASES OF THE ABDOMEN 

Sometimes the abdominal cavity becomes more or less filled with 
gas, which escapes h'om a perforation in the intestines, when phy- 
sical signs indicating this condition will be apparent. Other 
signs and symptoms such as pain, tenderness, bleeding, shock, 
condition of the pulse, etc., when present, are not of sufficient 
diagnostic import to determine a puncture of the intestines, as 
all of these may occur from a simple punctured wound of the ab- 
dominal wall. 

Penetrating Wounds of the Kidneys may involve the perito- 
neum and in some cases the injury wounds the posterior part of 
the kidne}^, when the peritoneal cavity is not opened. The pass- 
age of urine through the wound would serve to indicate an injury 
to the kidney. Blood is sometimes passed in the urine, although 
this is not constant. There is pain in the bladder which is trans- 
mitted to the groin, testicle or thigh. If the wound is extra peri- 
toneal, the prognosis is much better than if the peritoneal cavity 
itself has been opened. Abscesses sometimes complicate this 
class of injuries, and when present greatly prolong disability. 

Bladder Wounds are common when a deep puncture of the 
abdorhinal wall over the region of this organ exists. The diag- 
nosis is easily made by the passage of urine through the wound or 
in cases where the contents of the bladder are emptied into the 
abdominal cavity, absence of urine in the bladder is sufficient to 
make the diagnosis of a puncture, or the use of the cystoscope 
will make the condition clear. The prognosis of these injuries is 
determined according to the location of the puncture in the walls 
of the bladder; if interperitoneal, general peritonitis follows and 
death soon ends the case. In extraperitoneal injuries, the urine 
infiltrates into the connective tissue of the abdomen, perineum, 
scrotum and often extends into the thighs; producing sloughing 
and -greatly prolonging disability; subperitoneal punctures may or 
may not produce peritonitis. 

' TOTAL DISABILITY following punctured wounds of the 
abdominal wall which do not penetrate into the peritoneal cavity 
require from i to 2 weeks for all classes of risks, unless there is 
a large amount of laceration compHcating the puncture, when 
total disability of from 2 to 3 weeks may be necessary. If the 
punctured wound becomes a penetrating one and infection of the 
peritoneal cavity ensues. — to be followed by peritonitis, — total 
disability is generally ended by death of the individual within 7 
days. If the wound injures some of the contents of the abdominal 



HERNIA 151 

cavity and these are repaired at once or before general peritonitis 
develops, total disability usually lasts from 4 to 6 or 8 weeks, un- 
less a complication such as an abscess of the peritoneal cavity 
or some other cause prolongs disability. Injuries to the bladder 
that are not fatal and which result in extravasation of urine into 
the connective tissues surrounding these parts, prolong disability 
for an uncertain time; usually, however, this complication is fol- 
lowed by recovery in 4 to 8 weeks, depending on the amount of 
sloughing which occurs. Perforating wounds which are compli- 
cated with peritonitis and followed by recovery are prolonged by 
this complication 2 to 3 weeks. 

PARTIAL DISABILITY of i to 2 weeks may be necessary 
in preferred risks when the wound involves the abdominal wall 
only. Ordinary risks are not entitled to any partial disability fol- 
lowing this character of wounds. If the injury is a penetrating 
wound and some of the organs of the abdominal cavity are in- 
jured, partial disability is allowable to that class of risks who are 
able to follow part of the occupation during the time required 
for complete recovery and this time may last from 3 to S weeks; 
rarely longer. 

EFFECTS : Punctured wounds of the abdominal wall only 
leave no bad effects; a scar, however, results, and is permanent. 
If the wound has involved any of the contents of the abdomen, an 
individual would not be insurable for any kind of insurance until 
at least one to two years had passed after complete recovery from 
the accident, and even then it is questionable if "an insurance com- 
pany would be justified in accepting persons who have suffered 
from punctured wounds of any of the important organs of this 
cavity. Such individuals who recover usually have the contents 
of the abdominal cavity strongly bound together by adhesions 
and more or less impairment of health results. 

HERNIA 

INFORMATION : When the term hernia or rupture is used 
alone, it generally means a protrusion of some of the contents of 
the abdominal cavity through an uncompleted opening in the ab- 
dominal wall w^hich is covered by skin. Such a condition is more 
common in the male and may occur at any time during life. It is 
due to any condition which forces some of the contents of the 
abdominal cavitv through a weakened spot in the anterior wall. 



152 



INJURIES AND DISEASES OF THE ABDOMEN 



Muscular efforts which are carried to excess, relaxation of the ab- 
dominal muscles, severe contusions, a sudden jerk of the body 
and pressure of the abdominal contents within and pressure on 
the abdominal walls are some of the causes which produce this 
condition. Da Costa says ''a hernial sac may exist for years and 
remain empty. When bowel or omentum enters it from some 
strain or effort, the parts w^ere long prepared to receive the ex- 
truded mass. This extrusion may occur gradually; it may occur 
suddenly. If it occurs suddenly, the sufferer beheves that his 
hernia was formed then and there, but, as a matter of fact, the 
extrusion of bowel or omentum and its entrance into the sac are 
but the last of a long series of antecedent and preparatory changes. 
Finally, a hernia appears, and usually does so during effort. In 
rare cases, traumatism may cause a hernia immediately, no sac 




FIG. 32.— LOCATION OF VARIOUS FORMS OF ABDOMI- 
NAL, HERNIAE (DIAGRAMMATIC.) ( Eisendrath ). 

U. Umbilical hernia: D, direct inguinal hernia; B, in- 
direct incomplete inguinal hernia; O, complete or scrotal 
inguinal hernia; F, femoral hernia. 



HERNIA 



15» 



existing before the accident." Accident policies visually cover 
disability from a rupture for a limited period only, this is because 
an individual who becomes ruptured might refuse to wear a 
truss and claim disability for an indefinite period. Any one suf- 
fering from a rupture should be totally disabled no longer than 
the time necessary for securing a well fitting truss and that should 
not be more than two or three days at the longest in any section 
of the United States. Hernia which becomes strangulated at the 
time it occurs and necessitates an operation, is covered by an ac- 
cident policy and the company would be liable for the time re- 
quired for recovery. When an individual has been suffering from 
a rupture for some time and voluntarily undergoes an operation 
for its cure, he is not entitled to indemnity under an accident or 
disability policy. If the operation is performed on account of the 
hernia becoming strangulated, then a disability policy would cover 
the loss of time. 

SIGNS AND SYMPTOMS: Immediately following a tear 
in the abdominal wall, there is swelling with a sickening feeling 




Pig. 33. — Oblique inguinal hernia or rupture oi" left side. (,HtM-g~>. 

and a desire to support the part injured; vomiting sometimes oc- 
curs. At the opening in the abdominal wall is noticed a small 



154 



INJURIES AND DISEASES OF THE ABDOMEN 



soft tumor which disappears on pressure and also when the indi- 
vidual is in a recumbent position; on coughing an impulse is felt 
at the opening and the tumor, if not supported, is increased in 
size. 

DIFFERENTIAL DIAGNOSIS: When an inguinal hernia 
exists, several forms of swelling may be claimed as hernias; in 
addition an old hernia may be said to be a recent one and the re- 
sult of an accident. A rupture of some standing, unless supported 




Fig. 3,. — Hernia and hydrocele in the same patient. Hy, 
hydrocele sac, pushing the testis (T) downward and behind 
it; He. left indirect complete or scrotal hernia. (Eisendrath). 



^ 



by a truss from the beginning, shows a considerable opening in 
the abdominal wall, and sometimes when the omentum forms the 
hernia, adhesions bind the protrusion in place and it is not re- 
ducible, thus serving to show that it is of long standing. An in- 
dividual who has suffered from a hernia for some time shows on 
his body the marks of a truss; these marks being seen behind 
where the pads rest and also in front over the rupture; besides 
there is a thickening of the skin under the pads which results 
from pressure, while a dark red discoloration of the skin generally 
exists at the same place. If these are not apparent on account of 



HERNIA 155 

the truss not having been worn very long, the hair on the pubis 
is worn off by the strap which connects together the two anterior 
ends of the truss. 

Hydrocele is often mistaken for a rupture. This sweUing is 
pyriform in shape and commences at the bottom of the scrotum, 
it is semi-fluctuating, transmits no impulse on' coughing, is dull on 
percussion, and when a light is held behind the tumor, it is trans- 
lucent and shows the testicle to be behind and at the lower part 
of the swelling. There may be scars from one or more punctures 
in old-standing cases of hydrocele which are claimed as due to 
accidents, if these marks are found, it is evidence that a hydrocele 
has existed, but that does not preclude a hernia also existing. 

Hematocele or a collection of blood in the scrotum appears 
suddenly as the result of an injury to this part of the body. Ex- 
amination shows no impulse on coughing, and if felt between the 
fingers the impression of holding a mass of dough is given. When 
a light is used, the swelling is opaque; in addition to these signs 
and symptoms there is a clear history of an accident with result- 
ing discoloration of the scrotum and in many cases abrasions. 
Such injuries are usually complicated with other injuries of the 
body which would serve to prove that the condition is a recent 
one and accidental in origin. 

Varicocele should never, be taken for a rupture, although this 
condition is diagnosed as such. Pressure reduces the enlarged 
and distended A^eins which readily fill up again when it is relieved 
or placed over the inguinal ring, thus showing that the condition 
is not a hernia. 

COMPLICATIONS: A Strangulated Hernia is liable to oc- 
cur when a hernia is sustained, especially if there is a large pro- 
trusion of the intestines at the time the hernia is produced: such 
a condition is sometimes reducible without an operation, and if 
not, this is necessary at once for the preservation of life. 

TOTAL DISABILITY following a simple, uncomplicated 
hernia should not last any longer than the time required for the 
individual to secure a truss, because as soon as a truss is put on. 
disability ends, and from 2 to 5 days are ample in such cases. 
When a truss is first adjusted it causes excoriation of the skin 
luider the pads, some pain and discomfort, but this is not sutli- 
cient to produce disability of any kind. If a hernia beconios stran- 
gulated at the time it occurs and is reducecl withont an i^iHM-ation. 
total disability generally lasts from 7 to to days: if an operation 



156 INJURIES AND DISEASES OF THE ABDOMEN 

is required, indemnity of 4 to 6 weeks is payable to preferred 
risks. Ordinary cases sometimes require i to 3 weeks longer 
than the above time following an operation for a strangulated 
hernia. 

PARTIAL DISABILITY is not often allowable to any class 
of risks following a hernia which may be received accidentally. 
Sometimes total disability is prolonged for various reasons and 
the individual becomes weakened; in such cases, partial disability 
in preferred risks of from i to 3 weeks is necessary. Ordinary 
risks do not resume their labor until capable of doing a full day's 
work, consequently they are not entitled to any of this disability. 

EFFECTS: Individuals who have suffered from a hernia 
and wear a well fitting truss are insurable for any kind of insur- 
ance from one to two m.onths after the injury occurs, provided 
all policies contain a waiver eliminating disability or death, if a 
truss is not worn constantly while in the upright position. If an 
operation for a strangulated hernia is necessary, the claimant is 
not insurable until three to six months after complete recovery, 
arid even at that time it would be good underwriting to consider 
each case by itself. 

SUPPURATION OF THE INGUINAL GLANDS 

INFORMATION: The most frequent cause of abscess of 
the glands of the groin is venereal disease, although an accident is 
usually claimed to have produced the suppuration. Any point of 
infection which is in the area drained b}^ these glands may produce 
a suppuration of them. Some individuals suffering from an ab- 
scess of these glands claim that the suppuration is the result of a 
blow or due to straining in an attempt to lift a heavy object. 
Prominent genito-urinary specialists see one or two cases of sup- 
puration of the glands of the groin as the result of an accident in 
a life time; it can therefore be seen how extremely rare is this con- 
dition following an accident. An individual is entitled to indem- 
nity under an accident or disability policy, when a suppuration of 
the inguinal glands occurs and is accidental in origin. Some in- 
surance companies issue disability policies which pay indemnity 
for loss of time without regard to the cause, and even though an 
abscess of the glands is venereal in origin, the company is liable 
under such a poHcy. Very few men, however, claim indemnity 
for disabihty when it results from disease of the genital organs. 



SUPPURATION OF THE INGUINAL GLANDS 157 

On account of abscess of the glands of the grom being almost in- 
variably caused by venereal infection, all claims alleging disability 
as due to this cause should be closely investigated, and if this is 
done properly, the company is almost sure to obtain evidence that 
the suppuration is due to disease and is not accidental in origin. 

SIGNS AND SYMPTOMS : Individuals suffering from in- 
fection of these glands allege a history of an accident and usually 
state that the glands have been injured in lifting; they claim pain, 
tenderness and inability to work on account of the swelhng that 
appears and which in some cases goes on to suppuration. In- 
creased pulse rate and slight elevation of temperature are present 
in suppuration of these glands. 

DIFFERENTIAL DIAGNOSIS is easily made in such con- 
ditions. If the suppuration is actually due to an accident, there is 
evidence of a blow and discoloration which is characteristic of an 
extravasation of blood under the skin and not the red, purphsh 
discoloration which accompanies an abscess. If the abscess is the 
result of venereal disease, there is evidence of such existing. If 
no discharge from the penis exists, a specimen of urine will con- 
tain pus and shreds of mucus which prove that a urethritis is 
present. 

Syphilis can be existing at the time and cause an enlarge- 
ment of these glands, and this may be accompanied by a suppura- 
tion which is not due to the syphilitic infection. When the indu- 
ration is caused by syphilis, it always attends or follows a chancre. 
The glands that are involved are freely movable and no inflamma- 
tory symptoms are present, the skin being normal and not ad- 
herent to them. This condition is painless and rarely suppurates 
unless it is caused by a mixed infection. 

COMPLICATIONS: Venereal Disease of some kind almost 
invariably compHcates an abscess of the glands of the groin and 
can be diagnosed if the proper methods are emplo3^ed. 

TOTAL DISABILITY from suppurating glands of the 
groin in preferred risks when the cause is accidental in origin, re- 
quires from I to 2 weeks. Ordinary risks generally demand from 
2 to 3 weeks of this disability. All risks suffering from an abscess 
of the glands of the groin when the cause is a venereal infoolion. 
require from i to 3 weeks of total disability. 

PARTIAL DISABILITY of i to 2 weeks is payable to pre- 
ferred risks suffering from this condition when caused by an acci- 
dent Partial indemnitv for total disability under a health policy 



158 INJURIES OF THE BACK 

in the same class of risks when the abscess is due to venereal dis- 
ease may require from 2 to 4 weeks. Ordinary risks are not en- 
titled to any partial disability. 

EFFECTS : After complete recovery a scar remains, and if 
the disability has been due to an accident, the individual is insur- 
able for any kind of a policy from three to four months after com- 
plete recovery. An insurance company would hardly issue an ac- 
cident or health policy to any person who had made a claim for 
disability when the cause was a venereal disease; the reason of 
this being due to the increased moral hazard which exists in these 
cases. Life insurance can be written from three to six months 
after an infection due to gonococci has been cured, but if syphilis 
has existed, insurance of every kind is denied the individual in the 
majority of cases. When a w^ell authentic history of treatment 
for two to three years with absence of signs and symptoms for 
three to five years after the termination of the treatment is ob- 
tained, insurance of all kinds can usually be granted. 



PART III 

INJURIES OF THE BACK 

ABRASIONS AND CONTUSIONS 

INFORMATION : AMien an injury of any character is sus- 
tained to the back and is described as involving this part of the 
body, it usually has reference to that part which extends from the 
base of the neck to the rim of the pelvis. Abrasions of the back 
are rarely seen except in conjunction with other and more serious 
injuries involving some other part of the body, when the period 
of disability is controlled by the character of the more severe in- 
jury. Contusions of the back commonly occur and result from 
any blow which may be applied directly to any part of the back 
or by indirect force, such as falls in which the body alights on the 
feet, buttocks, shoulders or sides. These contusions are mostly 
complicated with sprains involving some part of the vertebral 
column. 

SIGNS AND SYAIPTOMS: Abrasions of the back produce 
the same symptoms in this locality as seen in other parts of the 



ABRASIONS AND CONTUSIONS OF THE BACK 159 

body; namely, an abraded surface followed by bleeding, scabbing 
and sometimes suppuration with slight pain and tenderness. Con- 
tusions produce slight swelling, but extensive discoloration, with 
pain, tenderness and inability to bend the body forward or back- 
ward or to turn from side to side without causing much pain. If 
the blow is in the region overlying the kidneys and these organs 
are injured, there is severe, locaHzed pain followed by urinary 
symptoms, such as a constant desire to micturate with the passage 
of small quantities of urine and in some cases bloody urine or pure 
blood, according to the severity of the injury. Bleeding from the 
kidneys may persist from one to three or four days and gradually 
disappear as the organs recover. 

DIFFERENTIAL DIAGNOSIS: Tumors and Swelling of 
the back which may have been present for some time and caused 
by other conditions m.ay be claimed as the result of a contusion. 
Discoloration which is characteristic of a contusion is absent when 
the swelling is due to tumors or other causes, unless it has been 
intentionally produced by repeated slight blows over the swelling 
or by the subcutaneous injection of tincture of iodine. Pain and 
tenderness are not usual in tumors which have been existing for 
some time and although claimed by a malingerer, the absence of 
such could be proved by making pressure over the tumor when 
the attention of the individual is on another subject. Increase in 
the rate of the pulse almost invariably occurs when the pressure 
is made over a painful area, and this would not be present when 
pressure is made over a tumor mass. A beginning abscess seen 
in the early stages may be said to be due to a blow; in such cases 
there is swelHng and signs of inflammation, such as redness, in- 
creased temperature over the part, with pain and tenderness 
which is more acute than if following a contusion, but the char- 
acteristic discoloration of a contusion is absent. 

Muscular Rheumatism is one of the most frequent causes of 
disability which is said to be due to a contusion or a sprain of 
the back, and is extremely hard to diagnose or prove that the 
condition is due to disease, rather than the result of an injury as 
claimed. This disease involves the voluntary nniscles and is 
usually bilateral, coming on after exposure to cold or dampness 
or following a previous attack. The onset of the disease is sud- 
den, with stiffness in the muscles involved, severe pain, tenderness 
and much difficulty on movement. Spasm of the affected muscles 
mav occur which would not be seen following- a contusion. The 



160 INJURIES OF THE BACK 

duration of this condition is about one week, although it may be 
prolonged when the weather is unfavorable. 

COMPLICATIONS: Sprains involving some of the joints 
of the vertebral column usually complicate a severe contusion of 
the back, but such is not the case when slight abrasions or contu- 
sions are suffered. Injury of the kidneys may follow severe blows 
to the lower part of the back or side, when disability is generally 
prolonged. 

TOTAL DISABILITY following simple abrasions of the 
back which are uncomplicated by any other injury should not be 
allowed to any class of risks. Preferred risks are entitled to i to 
2 weeks of fhis disability when a severe contusion has been sus- 
tained and no complications are present. Ordinary risks usually 
require from i to 3 weeks of total disability following severe con- 
tusions of this part of the body. If any injury to the kidneys oc- 
curs at the time, total disabiHty in all classes of risks usually lasts 
from 2 to 4 weeks. 

PARTIAL DISABILITY of i to 2 weeks may sometimes be 
necessary when the period of total disability has been short. Or- 
dinary risks are not often entitled to this form of disability. 

EFFECTS : Individuals who have suffered from a severe 
contusion of the back are insurable for any kind of a policy two to 
three months after the date of the accident, — provided no compli- 
cations have arisen. If the kidneys have been injured and disabil- 
ity has been prolonged thereby, an insurance company would 
hardly consider such a person for any kind of insurance until six 
to twelve months have elapsed, and even then not until a urinary 
examination has been made by a competent physician. 

INCISIONS AND LACERATIONS OF THE BACK 

INFORMATION: Incised or lacerated wounds involving 
the posterior surface of the body between the base of the neck and 
the buttocks result from contact with any substance which will 
lacerate the skin and underlying tissue more or less extensively. 
Such wounds cause short periods of disability and leave no per- 
manent impairment, unless the erector spin^ muscle is badly cut 
or torn or the injury involves some of the ligaments binding the 
segments of the vertebral column together. 

SIGNS AND SYMPTOMS are the same as seen in such in- 
juries to any portion of the body; pain, tenderness, swelling, bleed- 



INCISIONS AND LACERATIONS OF THE BACK 161 

ing, separation of the wound edges and some impairment of mo- 
tion may be noticed. 

COMPLICATIONS : Incised or Lacerated Wounds which are 
sufSciently deep, may enter the peritoneal cavity and result in 
peritonitis; usually, however, this class of injury is complicated 
only by infection which prolongs disability. 

TOTAL DISABILITY in superficial incised or lacerated 
wounds is not deserved by any class of risks unless a number of 
cuts are present, when 7 to lo days may sometimes be necessary. 
Deep incised wounds which require six or more sutures, or lacer- 
ated ones which cover a considerable area, demand from i to 2 
weeks of total disability. If these wounds become infected, this 
form of disability is usually prolonged about i week. 

PARTIAL DISABILITY is not often necessary following 
either incised or lacerated wounds to this part of the body. Pre- 
ferred risks sometimes require from 3 to 7 days of this disability 
following a short period of total disabiHty. Ordinary risks are 
not entitled to any partial disability. 

EFFECTS : A resulting scar, but seldom any deformity or 
disability, unless the incision or laceration has been very deep or 
involved a large surface, when the extensive scar which results 
may cause some inconvenience; but rarely disability. After recov- 
ery is complete, individuals are insurable for any form of policy. 

PUNCTURED WOUNDS OF THE BACK 

INFORMATION : Punctured wounds of the back result 
from the same causes as do punctured wounds of the chest or ab- 
dominal wall and are divided into non-penetrating and penetrat- 
ing. Non-penetrating wounds which involve only the posterior 
surface of the chest or abdominal cavities produce total disability 
for the length of time required for complete healing of the wound, 
while penetrating ones may enter the chest or abdominal cavities 
and injure some of the contents. For description of punctured 
wounds which injure any of the organs of the chest or abdominal 
cavities, see Punctured Wounds of the Chest or Abdomen. 

SIGNS AND SYMPTOMS : Shock almost invariably fol- 
lows a punctured wound which does not penetrate into either one 
of the cavities, the degree of which may be slight or severe. There 
is localized pain and tenderness, bleediuQ- from the wound and 



162 INJURIES OF THE BACK 

later if infection occurs, swelling and inflammation surrounding 
the puncture, with a discharge of pus. 

COMPLICATIONS : Infection is usual in punctured wounds 
involving any part of the body, and this is especially true if the. 
puncture is deep and made by an instrument of small calibre, as it 
is almost impossible to thoroughly cleanse such a wound and pre- 
vent infection. Marked elevation of temperature results when the 
infection is severe. 

Erysipelas or Tetanus is liable to occur, and especially the lat- 
ter when the puncture has been made by missiles from firearms, 
and if either one of these complications ensue, the usual signs and 
symptoms peculiar to the disease are evident. 

The Vertebrce of the spinal column may be fractured by punc- 
tured wounds and pressure on the cord supervene, when paralysis 
below the point of injury results and in many cases infection and 
death. 

TOTAL DISABILITY following punctured w^ounds de- 
pends on whether the wound is non-penetrating or penetrating; 
if the latter the length of time disability ensues is described un- 
der Punctured Wounds of the Chest or Abdomen. Total disabil- 
ity in uncomplicated non-penetrating wounds of the back, in pre- 
ferred risks, lasts i to 2 weeks; if infection occurs, total disability 
is prolonged 7 to 10 days in this class of risks. Ordinary risks 
are usually entitled to 2 to 3 weeks of total disability when the 
puncture has been deep and is followed by infection. Should 
erysipelas or tetanus complicate a punctured wound, total dis- 
ability is prolonged according to the time described under these 
diseases. 

PARTIAL DISABILITY is seldom necessary in any class 
of risks following a punctured wound of the back. 

EFFECTS : Punctured wounds which do not penetrate 
either one of the cavities of the trunk, leave no permanent de- 
formity, unless injury to the spinal cord has occurred, when in- 
surance of all kinds would be denied any one suffering from the 
result of such an accident. If the cord has not been injured, an 
individual is insurable for any kind of a policy from one to two 
months after complete recovery. 

BURNS AND SCALDS OF THE BACK 

INFOR]\IATION: Burns and scalds of the back may be in- 
flicted when that part of the body is bare of clothing or covered 



BURNS AND SCALDS OF THE BACK 



163 



by it. When the back is uncovered by any article of apparel, 
burns and scalds usually occur to males who work where hot 
metal and steam are- constantly employed. Burns and scalds to 
the back when it is covered by clothing also take place and result 
from hot metal, hot water, steam, acids or alkalies and are gener- 
ally more severe on account of the cause of the burns or scalds 
being confined under the clothing. These injuries are usually 
superficial, but extensive, and involve a more or less greater area 




-Burns of the back. (Keen). 



of this part of the body, but do not often extend deep enough to 
result in a punctured wound of the chest or abdomen from be- 
hind. 

SIGNS AND SYMPTOMS depend on the degree of sever- 
ity of the burn or scald. Usually, however, shock is the most pro- 
nounced symptom, manifesting itself by subnormal temperature 
and marked weakness and prostration. In addition there is pain, 
tenderness and evidence of the burn or scald or the action of acids 
or alkalies. Sometimes when hot metal has been confined, car- 
bonation results. When the scald is due to steam or hot water, 
it maybe superficial and onlv ]^roduce blisters, wliilo again it may 



1G4 INJURIES OF THE BACK 

be severe enough to cause a total loss of the tissues of the parts 
involved. 

COiMPLICATIONS: Infection almost invariably follows a 
burn or scald involving a considerable area of the back and pro- 
longs the period of disability. 

Necrosis of the processes of the vertebrae and also the pos- 
terior surface of the ribs, may sometimes result on account of se- 
vere and deep burns involving this part of the body. 

Neuritis of the intercostal nerves may complicate severe 
burns or scalds involving the back, especially if the burn has 
been sufficiently deep to affect the nerves at the point of exit from 
the spinal column. 

Fractures of the processes of the vertebrae, together with 
fractures of the ribs or the scapula, may result when a severe 
burn or scald is complicated with a fall or a severe blow from 
some heavy object which ma}- strike the body at the same time 
that the burn or scald occurs. 

SEQUELAE: Skin Grafting is almost invariably required 
when burns or scalds of the back exceed an area of four to five 
inches in diameter. AMien such an operation is necessary, the 
period of total disability is prolonged from two to three weeks 
for each operation. 

Scars which are more or less marked and which result in 
various degrees of contraction always follow severe burns of the 
back. If the scald has been very deep and some of the muscular 
tissue has been destroyed, the contraction from the resulting scar 
may limit the movement. 

Deformity and permanent injury may follow severe and deep 
burns involving the back, and this is especially true if a large area 
has been destroyed and the burn or scald has been deep and in- 
volved the muscular tissues. If a fracture has existed or necrosis 
of the bone resulted from the burn or scald, the degree of de- 
formity may be more pronounced. 

TOTAL DISABILITY generally follows in all classes of 
risks when the burn or scald if at ah deep has involved an area 
exceeding three or four inches in diameter. When a less amount 
of area has been burnt or scalded, total disability does not even 
exist in preferred risks. Ordinary risks usually require from i 
to 2 weeks of disabihty in burns which are of this size and mod- 
erately deep. Larger burns require from 2 to 3 weeks in pre- 
ferred risks and from 3 to 5 weeks in ordinary classes. Severe 



SPRAINS OF THE BACK 165 

burns or scalds of the back in which a considerable superficial 
area has been involved, together with extension to the deeper 
tissues usually demand from 4 to 6 or 10 weeks in all classes of 
risks, — this time depending on the location of the injury, the 
area involved and the severity, together with the depth of the 
burn or scald. Skin grafting is generally necessary when the 
burn or scald involves an area larger than four to five inches in 
diameter. Disability in such cases is usually prolonged from 2 
to 3 weeks for each operation. 

PARTIAL DISABILITY when allowed by the poHcy gen- 
erally requires from 2 to 4 or 6 weeks and sometimes longer, — 
this period of disability depending on the length of total disability 
which preceded it, the exact duties of the occupation, the area 
and degree of severity of the burn or scald and the subsequent 
history. When a large part of the back has been burnt or scalded 
by hot metal, water or steam which was confined under the cloth- 
ing, the period of partial disability may sometimes run the limit 
of the policy. 

EFFECTS : Burns and scalds of the back of any severity 
always leave scars which are first red and later become bleached 
and white. If the burn or scald has been deep, these scars con- 
tract in various directions, thus producing an ugly looking mass 
of scar tissue. Sometimes the scar is so situated that the deform- 
ity which results from it causes no impairment of motion or any 
visible deformity. Individuals who have suffered from severe 
burns or scalds of the back which have involved a considerable 
area and which was followed by healing, are insurable for any 
kind of a policy as soon as recovery is complete, and it could be 
decided that permanent deformity would not result. If the de- 
formity is sufficiently great to cause impairment of motion or 
prevent the individual from protecting himself in a case of emer- 
gency, an insurance compan}^ would hardly issue an accident or 
Hfe policy on such a person. 

SPRAINS OF THE BACK 

INFORMATION : Claims for disability alleging the cause as 
due to a sprain of the back are frequently received by insurance 
companies. Industrial accident and health insurance companies 
on account of these claims being so numerous usually have a 
clause in their policies stating that claims for disability resulting* 



166 INJURIES OF THE BACK 

from a sprain of the back will not be allowed for more than four 
weeks of total disability. Sprains of the back are due to any vio- 
lent twist or untoward movement involving this part of the body 
which tears or lacerates the muscular tissue of the back or any 
of the ligaments in connection with the vertebral column. Sprains 
W'hich cause short periods of disability are usually due to a tear 
of the muscles or fascia of the back, while severe sprains which 
result in prolonged periods of disability are almost invariably the 
result of a tear of the ligaments holding together the vertebrae 
of the spinal column. Acts of overexertion in which the indi- 
vidual attempts to lift a heavy object and persists in trying to 
lift such a weight until something gives way in the back or until 
a tear of the muscles, fasciae or ligaments occur, are not covered 
by an accident policy, for the reason that no accident has oc- 
curred, the individual in such cases producing the disability by an 
act of overexertion, and an insurance company will not acknowl- 
edge claims for disability when it is the result of such unwar- 
ranted acts. 

SIGNS AND SYMPTOMS following a sprain of the- back 
which occur more often in the lumbar region, are first pain w^hich 
is usually localized, later tenderness is present and sometimes 
swelling. Discoloration is rare in sprains of the back unless the 
tear of the muscles or ligaments has been marked. Certain 
movements, — and especially when bending forward, — generally 
increases the pain in sprain of the back when the ligaments of 
the spinal column have been torn. If the injury has resulted in a 
tear of some of the muscles of the back, there may be inability 
to resume the upright position after bending forw^ard, and when 
lying in bed it is oftentimes impossible for the legs to be moved. 
This apparent loss of power, together with pain and difficulty in 
securing movement of the bowels or the evacuation of the con- 
tents of the bladder, is usually not due to paralysis, but is caused 
by an effort on the part of the individual to save himself pain 
which results on the .slightest movement from severe sprains in- 
volving the vertebral column. 

DIFFERENTIAL DIAGNOSIS: Lumbago must always be 
differentiated from a sprain of the back. This disease frequently 
comes on suddenly when the individual is in a stooping position. 
\Mien it is present, an inflammatory condition of the muscles ex- 
ists with severe pain on the slightest movement in any direction, 
tenderness over the inflamed muscle which is usuallv on one 



SPRAINS OF THE BACK 167 

side, although sometimes both sides are affected, stiffness and 
rigidity of the muscle involved and generally a history of a previ- 
ous attack or a history of exposure which might result in this 
disease. Disability from lumbago does not often last more than 
from one to two weeks, while a sprain of any degree of severity 
is never recovered from in this length of time. 

Dislocations of the cervical vertebrae are sometimes supposed 
to exist when a sprain has occurred to this part of the body, — 
this being due to the fact that the individual holds the head in a 
fixed position and usually to one side. When this position is as- 
sumed, the transverse processes are more prominent on one side 
than on the other, thus giving rise to the assumption that a dis- 
location of these processes has occurred. 

COMPLICATIONS: Concussion of the Spine not infre- 
quently complicates a sprain of the back, but this subject is con- 
sidered under a special article, — Concussion of the Spine. 

Inflammation of the intervertebral disks sometimes follows a 
severe sprain of the back in which some of the ligaments of the 
spinal column are torn. When this condition exists there is in- 
ability to stand on the feet, a slight blow on the top of the head 
or soles of the feet causes severe pain at the point of inflamma- 
tion, there is usually some swelling and extreme tenderness with 
pain at the point of injury which persists for a considerable 
period of time. 

Fractures and Dislocations of the vertebral column may com- 
plicate a severe sprain of the back, but in this case the complica- 
tion is more serious than a sprain, and information concerning 
this is described under Fractures and Dislocations of the Spine. 

SEQUELAE : Caries of the Vertebrcu is said to follow severe 
sprains of the back in which the ligaments of the spinal column 
have been torn and inflammation of the intervertebral disks ex- 
isted. In such cases this condition would not manifest itself until 
some weeks or months after the date of the original injury. 

Softening of the Spinal Column on account of localized inflam- 
mation which is due to a severe sprain of the back involving sonie 
of the ligaments or intervertebral disks may result from a severe 
sprain in this part of the body. In such cases various signs and 
symptoms, such as a change in the reflexes in the lower extrem- 
ity, incoordination of the movements of the feet and legs, with 
sometimes motor and sensory paralysis follow. 

TOTAL DISABILITY in preferred risks suffering from 



168 INJURIES OF THE BACK 

.slight sprains of the back involving the muscular tissues usually 
does not last longer than from i to 2 weeks. When the injury 
involves the ligaments connecting the spinal column and is un- 
compHcated, total disability in this class of risks may last from 

2 to 4 weeks and sometimes longer, when complications super- 
vene. Ordinary risks are generally totally disabled from 2 to 4 
weeks when a severe sprain of the muscles of the back occurs, 
and from 4 to 6 or 8 weeks when the injury has involved the liga- 
ments connecting the spinal column. 

PARTIAL DISABILITY is seldom payable to ordinary 
risks following an injury of this kind, for the reason that they are 
not able to assume any part of their occupation until all of it 
can be taken up. Preferred risks, however, demand from i to 

3 or 6 weeks of this form of disability, — this time depending on 
the character of the injury, the location, its severity, the treat- 
ment and the exact duties of the occupation. 

EFFECTS : Individuals having suffered from a sprain of the 
back which involved the muscular tissues only are insurable for 
all kinds of insurance as soon as recovery takes place. When the 
injury has been more severe and some of the Hgaments of the 
spinal column have been torn, — and especially if any complica- 
tions such as so-called concussion of the spinal cord or inflamma- 
tion of the intervertebral disks follow the injury, — such persons 
are usually uninsurable for any kind of insurance until two to 
four months after the termination of disability and it is known 
that no after effects are present. 

FRACTURES AND DISLOCATIONS OF THE 
VERTEBRAE 

INFORMATION: Fractures and dislocations of the bones 
forming the vertebral column usually occur together, it being 
said that a dislocation existing between the bones of the spinal 
column without a fracture is exceedingly rare; so also is it 
claimed that a fracture without a dislocation seldom exists, al- 
though fractures iqvolving some of the processes and laminae 
may be present without being complicated with a dislocation. 
Fractures and dislocations of the vertebral column are either the 
result of direct or indirect force. Direct force when the blow is 
applied directly to some part of the spinal column and indirect 
when the body is twisted or falls from a height and lands on the 



FRACTURES AND DISLOCATIONS OF THE VERTEBRAE 



169 



head or feet. When a violent bending backward occurs the pro- 
cesses of the vertebra are usually fractured, while the interverte- 
bral cartilages are badly torn. A dislocation of the bodies of the 
vertebrae is caused by a twisting or bending forward or back- 
wards. Fractures and disloca- 
tions of the spine mostly in- 
volve the cervical and dorsal re- 
gions, the atlas and axis being 
more frequently fractured, and 
when either of these bones is in- 
volved death is instantaneous. 
If a sHght dislocation of any of 
the bones of the spinal column 
occurs and the cord is slightly 
injured, death generally follows 
at a later date on account of the 
succeeding disease of the cord. 

SIGNS AND SYMPTOMS 
depend on the mode of occur- 
rence of the accident, the loca- 
tion of the injury and its sever- 
ity, whether the cord is injured 
or not. Displacement follow- 
ing a fracture or dislocation of 
the bones of the spinal column 
is seldom marked, but when a 
fracture of the spines of the ver- 
tebrae exists, some irregularity 
is present and sometimes crepi- 
tus can be elicited. Swelling is 
apparent at the point of injury, 

and this is follow^ed by discoloration. Fractures and dislocations 
of the vertebrae produce pain which is increased by movement, 
tenderness at the point of injury and symptoms referable to the 
site of the cord-injury. If the spinal cord is injured above the 
third cervical vertebras death is instantaneous on account of the 
phrenic nerve being involved and respiratory movements pro- 
hibited at once. If injury occurs between the third and sixth cervi- 
cal vertebrae, paralysis according to the degree of cord-injury af- 
fects the muscles of the shoulder and other parts of the body with 
anesthesia below the points of injury. A fracture and dislocation 




Fig. 36. — Fractui-e-dislocation of 
spine, showing- crushing of the cord. 
(Eisendrath). 



170 INJURIES OF THE BACK 

of the vertebrae of the dorsal region produces paralysis below the 
point of injury and when the injury is in the upper dorsal region, 
the hemorrhage which follows may extend upward and involve 
the phrenic nerve, when death takes place at once. If the frac- 
ture and dislocation occurs to the vertebrae in the lumbar region, 
extreme pain in the legs is complained of, with paralysis of the 
lower extremities, the bladder and rectum. Fractures involving 
the spinal column should always be subject to an x-ray exami- 
nation if possible, for the purpose of ascertaining the extent of 
fracture and involvement of the cord. 

COMPLICATIONS: Fractures and Dislocations of the Ster- 
num often exist when the vertebrae have been injured by extreme 
flexion or hyperextension. If this complication is present, the 
breathing is interfered with and pain is present, together with 
deformity of the breast-bone. 

Fractures and Dislocations of the Ribs may be present when a 
severe twisting or forcible bending backwards or forwards has 
resulted in a fracture and dislocation of the vertebrae. Such a 
compHcation does not prolong disability should the spinal injury 
not be sufficient to cause death. 

Bed-Sores almost invariably supervene when a fracture of the 
spinal column exists and some injury to the cord has occurred, 
this being due to an altered nerve supply to the parts, pressure 
and the constant bathing of certain portions of the body by dis- 
charges from the bladder and bowels 

Chronic Cystitis usually follows when a fracture of the spinal 
column takes place, with a concomitant injury to* the cord. This 
cystitis is supposed to be due to the injury and also to the en- 
trance of pathologic germs into the bladder by the use of a cathe- 
ter which becomes necessary in such cases. 

Pyelonephritis follows an infection of the bladder if the indi- 
A'idual lives sufficiently long for the inflammation to travel up the 
ureters and involve the pelvis of the kidneys. 

TOTAL DISABILITY is extremely uncertain in cases suf- 
fering from a fracture and dislocation of the bones of the verte- 
bral column and death almost invariably follows these fractures, 
the location of the fracture oftentimes determining when the 
period of disability will be terminated by death. Total disability 
never exists when the fracture and dislocation involve the first 
and second vertebrae, death occurring instantly. \Mien any of 
the other cervical vertebrae are involved, death mav not take place 



CONCUSSION OF THE SPINAL CORD 171 

for twenty-four hours or perhaps i to -2 weeks. If the dorsal and 
lumbar vertebrae are injured, together with the spinal cord, the 
individual may be totally disabled and confined on his back on a 
water-bed for weeks or months and sometimes years before 
death finally takes place. 

PARTIAL DISABILITY is almost never present in cases 
of a fracture and dislocation of the vertebrae together with an in- 
jury to the cord, as an individual having suffered from such a 
condition rarely returns to work, and if so, the occupation is not 
resumed until practically all of it can be assumed. 

EFFECTS: Individuals with a history of having suffered 
from a fracture and dislocation of any part of the spinal column 
with or without an injury to the cord are uninsurable for any kind 
of a policy. 

CONCUSSION OF THE SPINAL CORD 

INFORMATION: Concussion of the spinal cord, according 
to some authors, is not a pathological condition, being merely a 
name given to a train of symptoms which develop after an injury 
occurs to the back and when a corporation is involved. These 
injuries are most frequently known under the term of ''railway 
spine," and a number of vague signs and symptoms are claimed 
to exist when a corporation is liable or supposed to be liable for 
the injuries inflicted. This condition is frequently assumed by 
malingerers for the purpose of securing money from some one, 
and these persons who become malingerers from trivial accidents 
involving the back or spinal column are most often women who 
have been more frightened than hurt in an accident on a street 
car, railway train or in some other manner which may result in 
liability for damages on the part of some one. The disability 
which ensues from these injuries and which is often due to mental 
impressions has been known to instantly subside in a court room 
when a verdict in favor of the plaintiff has been rendered by a 
jury.- In other cases when a favorable verdict has been received, 
recovery takes place within a very short time. A true concus- 
sion of the spinal cord, however, may exist from an injur}' such 
as a severe twist or blow which may produce an inflanunation in- 
volving the covering of the cord or a hemorrhage either within 
the dura or outside of it and sometimes within the substance of 
the cord itself. Such cases, of course, are not assumed and dis- 



172 INJURIES OF THE BACK 

ability which follows is legitimate, but these cases if the}' recover 
do so gradually and litigation has no effect on the time required 
for recovery. 

SIGNS AND SY^IPTO:\IS following concussion of the 
spinal cord are the most vague of any injury alleged to have been 
suttered by a claimant. Almost any sign or S3'mptom may be 
expected to develop in such a condition. Pain is always com- 
plained of in the spinal column, yet when tapping the head or 
soles of the feet, such a claimant can never pomt out any special 
point where the pain is aggravated by such a procedure, thus 
proving that no point of inflammation exists between the verte- 
brae themselves, and practically proving that none exists within 
the spinal column. Tenderness is said to exist at various places 
along the course of the spinal column. If there has been an ac- 
tual injur}^ and tenderness does really exist, it is always in the 
same place, and even when diverting the mind of the claimant 
and making pressure at the point of tenderness, pain is always 
elicited. IMannkopff discovered the fact that if tenderness actu- 
ally existed at a certain point that firm pressure at such a place 
produced acceleration of the pulse, the frequency of the pulse 
not being affected when tenderness is said to exist at various 
places when in reality it is not present. Nervousness is invariably 
complained of in stich an injury, the individual stating that the 
least noise produces nervousness, that on account of this condi- 
tion sleep is interfered with and that this nervousness results in 
fear of various things,, such as a person being afraid to undertake 
a railway journey, a ride on a street car, in an automobile, de- 
scend in an elevator, etc. Physical weakness is generally com- 
plained of and inabilit}' to properly concentrate the mind on the 
usual duties of the occupation when the occupation requires such 
concentration, is almost invariably alleged to exist. Paralysis is 
often claimed to exist, btit according to Walshamx, an English 
surgeon, "in cases of paralysis after an accident, no lesion of the 
vertebral colimm or of the spinal cord has been discovered." A 
severe shaking up, a jolt or blow over the spinal column which 
produces some injury to the cord itself results in pain and tender- 
ness at well marked places. In addition there is nervousness 
which gradually disappears and leaves no untoward effect. Such 
a jarring or shaking of the cord not infrequently produces con- 
stipation or diarrhea and sometimes difficulty in urination or re- 
tention follows. 



I 



CONCUSSION OF THE SPINAL CORD 173 

DIFFERENTIAL DIAGNOSIS between signs and symp- 
toms which actually exist and those which are reported to be 
present is sometimes an exceedingly difficult matter. Usually, 
however, a malingerer is easily detected. Signs such as wasting 
of muscles, paralysis which does not disappear under ether, ankle 
clonus, inability to control the movements of the rectum or blad- 
der or any positive sign or symptom which indicates a lesion of 
the cord is sufficient to prove that such a condition exists. Claim- 
ants who are not actually suffering from any injury to the spinal 
cord usually allege nervousness, impairment of vision, inability 
to concentrate the mind, loss of sexual power, increased and ex- 
aggerated knee jerks, and pain and tenderness at various points 
along the spinal cord which cannot be verified and tenderness 
which is not present when the mind is diverted. In addition there 
are a number of other vague signs and symptoms which have no 
bearing on the case and which should not be considered as exist- 
ing unless some signs and symptoms positively prove that the 
condition is as claimed. When rigidity or spasm of the muscles 
of the back on one side is present, it is an indication of an injury, 
as such a condition can rarely if ever be produced without a cause. 

Malingerers probably develop more frequently from injuries 
which may or may not involve the spinal column than any other 
class, for the reason that they can allege that various vague signs 
and symptoms exist. These are sometimes hard to disapprove 
by a medical examination as not being present, and the only way 
to- prove that they are malingerers is to pay them a certain sum of 
money and secure a release for the corporation which is held to 
be liable, when all the signs and symptoms referable to the al- 
leged injury immediately disappear and the individual is in per- 
fect health again. A sum of money in such cases is the best treat- 
ment that these people can receive, and unfortunately from a 
moral standpoint it is the only way in many instances to cure 
them. 

Traumatic Hysteria according to Da Costa develops only in 
those predisposed by a neuropathic hereditary tendency, while 
traumatic neurasthenia may arise in anybody. In flie first disease 
the accident is only the exciting cause; in the second disorder it 
is the cause. Traumatic hysteria is more frequent in females than 
in males, — its most pronounced effect being more on the mind 
than on the body. An individual of a neurotic disposition and 
having suffered from an accident luMieves that various symptoms 



174 INJURIES OF THE BACK 

are in existence and more or less disability exists. Actual areas 
of pain or tenderness are greatly magnified, and from small be- 
ginnings great pain, large areas of tenderness and many poorly 
described symptoms follow. 

Caries of the Vertebrce does not result from a concussion of 
the spinal cord. If such a condition is present, it was there be- 
fore the alleged accident took place. Caries is diagnosed by pain 
which has existed for weeks and months. On tapping the head 
or soles of the feet, increased pain is elicited at the location of the 
diseased bone. When caries exist, the vertebrae are immovable at 
the point of disease and curvature of the spine is usually apparent. 

TOTAL DISABILITY from injuries to the spinal cord 
which tear and lacerate the small blood vessels and nerves in 
preferred risks produce various lengths of disability. When the 
individual is not neurotic and the occupation is more profitable 
than would be the indemnity which would be secured from a cor- 
poration which may or may not be liable, this period of disability 
does not last longer than from 2 to 3 or 4 weeks. If the injury 
occurs to females and those of a highly nervous temperament, 
total disability in such a class of individuals is extremely uncer- 
tain, sometimes lasting weeks and months, the injury in such in- 
stances being magnified and disability greatly prolonged on ac- 
count of the mental condition. Total disability in individuals who 
have no incentive to return to work and who think that by re- 
maining idle they will receive more damages from a corporation, 
are usually totally disabled until a decision has been reacned 
through the court. 

PARTIAL DISABILITY following an injury to the spinal 
cord does not often exist in any class of risks, for the reason that 
the individual can usually resume all the duties of the occupa- 
tion when part of them are taken up again. 

EFFECTS : Injuries to the spinal cord that are not pro- 
duced in connection with a fracture or dislocation and which re- 
sult in short periods of disability have no effect on the insurabil- 
ity of the risk from three to six months after recovery is said to 
have been complete. Individuals with a history of having suf- 
fered such an injury and who make protracted claims on an in- 
surance company or corporation which may be liable for the in- 
jury are uninsurable for any kind of a policy on account of the in- 
creased moral hazard which exists. 



CHAPTER IX 

INJURIES AND DISEASES OF THE MALE SEXUAL 
ORGANS AND SURROUNDING PARTS 

ABRASIONS AND CONTUSIONS 

INFORMATION : The injuries most commonly seen in- 
volving the penis, scrotum, testes and perineum are abrasions and 
contusions and these usually follow from blows delivered to this 
part of the body, or from falls in which the body alights astride 
of some hard object These injuries may be trivial, causing little 
or no disability or what apparently is a trivial injury may cause 
prolonged disability and permanent deformity. 

SIGNS AND SYMPTOMS indicating injuries to these 
parts are noticed immediately after they occur. A dull nauseat- 
ing pain instantly follows a blow involving the" scrotum and 
testes and this in turn is quickly succeeded by swelling, but no 
alteration in the original shape of the parts affected. Extensive 
discoloration of the skin is an early and prominent sign; this 
usually appearing within the first twelve to twenty-four hours 
and remaining for a considerable time. AVhen an injury to these 
parts is sustained, nervous shock is one of the prominent symp- 
toms and persists for a variable length of time, according to the 
severity of the injury and the temperament of the individual. 

DIFFERENTIAL DIAGNOSIS between accidental in- 
juries to the male sexual organs and diseases of the same is ex- 
tremely important, as a number of claims are made under acci- 
dent policies when the disability is caused by disease. An acci- 
dent if seen before the external signs are obliterated, shows uni- 
form swelling of the parts with discoloration. Tenderness is 
present, but this never involves the cord of the injured side or 
sides, unless the blow^ has been extensive and has been sustained 
over the course of the cord when it is tender on pressure. If 
the swelling of the parts is due to venereal disease, the passage 
of urine will always show shreds of mucus floating in it, while if 
the injury is accidental in origin and no old existing venereal dis- 

175 



176 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

ease is present, it will be clear of these shreds. These two points, 
— absence of tenderness over the cord and clear urine, — are sufti- 
cent for diagnosing an accident and when present invariably in- 
dicate disease of the urethral canal. Injuries to the scrotum gen- 
erally involve both testes, while venereal disease usually affects 
one; the left most commonly. 

COMPLICATIONS: Venereal Disease may complicate an 
accidental injury to the male sexual organs, and if it does, insur- 
ance companies will not pay indemnity under an accident policy 
for the reason that the majority of policies eliminate indemnity 
when due to .or complicated by venereal disease of any kind. 

TOTAL DISABILITY in preferred risks suffering from an 
abrasion or contusion involving these parts, seldom lasts more 
than from i to 2 weeks. If the contusion has been moderately 
severe and has injured the urethra or one or both testes, total 
disability may last from 2 to 3 or 4 weeks in the same class off 
risks. Ordinary risks suffering from abrasions and contusions of 
these parts usually require from i to 2 weeks more than preferred 
risks; this being due to the fact that the upright position is 
usually demanded in the occupation with more or less move- 
ment, consequently such a person is unable to resume the occu- 
pation as early as a preferred risk. 

PARTIAL DISABILITY of from i to 2 or 3 weeks is al- 
lowable to preferred risks who have suffered from an injury to 
these parts; this time depending on the location of the injury, 
its character and severity. Ordinar}^ risks are seldom entitled to 
any partial disability. 

EFFECTS: Abrasions and contusions to the male sexual 
organs and surrounding parts w^hich do not result in permanent I 
deformity or disability, render the individual insurable for all 
kinds of insurance as soon as recovery is complete. If a swelling 
of the testes follows a blow and is slow in disappearing, a sarcoma 
may result. In such cases all kinds of insurance would be with- 1 
held until a competent medical report showed no malignant dis- * 
ease to be existing. 

INCISIONS AND LACERATIONS OF THE MALE 
SEXUAL ORGANS 

INFORMATION: Injuries w^hich tear and lacerate the 
male sexual organs are usually a degree beyond abrasions and 



INCISIONS AND LACERATIONS OP MALE SEXUAL ORGANS 177 

contusions. On account of the pliability of the skin covering 
these parts, lacerations are not very extensive externally, but the 
parts between, such as the urethra, blood vessels and cord in 
the scrotum are the ones generally involved and badly injured. A 
fall astride of a hard object seldom ruptures the skin of the penis, 
but frequently causes a partial rupture of the urethra; the same 
also applies when the scrotum is violently injured, the skin sel- 
dom being broken, but the contents of this sac may be badly 
injured. 

SIGNS AND SYMPTOMS depend on the parts involved in 
the accident. If the urethra is injured or partially torn, blood is 
passed involuntarily or with urine from the meatus. This is ac- 
companied by violent pain and much nervous shock. When the 
urethra is ruptured, the location is usually in the region of the 
bulb. If the rupture is posterior to an old stricture, retention of 
urine with extravasation -into the perineal tissues may result. Se- 
vere injuries which lacerate the soft tissues of the scrotum pro- 
duce a sickening pain, together with swelling and much discolora- 
tion. If the extravasated blood becomes infected an abscess re- 
sults. Should the cord leading from one or both testes be in- 
volved in the injury, atrophy follows, but this is not apparent 
until some weeks or months after the swelling subsides. 

COMPLICATIONS: Perineal Abscess frequently follows a 
rupture of the urethra due to the extravasation of blood and urine 
into the perineal tissue. When this condition occurs, total dis- 
ability is increased according to the length of time required for 
the evacuation of the abscess and complete healing. 

Extravasation of blood and urine into the perineal tissues is 
one of the frequent complications following a rupture of the 
urethra. This condition sometimes disappears without an oper- 
ation, but usually an incision must be made into the perineum 
for the purpose of drainage and frequently this becomes infected 
and an abscess results as above described. 

Atrophy of one or both testes follows a severe contusion and 
laceration involving them, with or without injury to the cord. If 
the cord is severed, atrophy of the corresponding testicle results, 
and if the other testicle for any reason or other is diseased, steril- 
ity follows. 

Epididymitis may follow a severe blow or laceration of the 
testicle. Usually, however, this inllammation is due to venereal 
disease and when the result of the latter, evidence of a discharge 
.12 



178 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

from the penis is present or shreds of mucus are found in the 
urine. 

TOTAL DISABILITY following incisions and lacerations 
involving these organs depends greatly on the extent of the in- 
jury and the parts involved. When the urethra is torn and prop- 
erly sutured at once, total disability in all classes of risks may last 
from 3 to 6 weeks only, while if good union is not secured, this 
form of disability may be very indefinite, lasting from i or 2 to 
4 or 6 months and sometimes even longer. Incisions and lacera- 
tions involving the testes produce total disability of from 2 to 4 
or 6 weeks in preferred risks; this time depending on the sever- 
ity of the injury and the exact duties of the occupation. Ordi- 
nary risks are disabled by these injuries from 3 to 6 or 8 wxeks. 
"^ PARTIAL DISABILITY in preferred risks following in- 
juries to the urethra may require from 2 to 4 or 6 weeks. In 
the same class when the injury involves the scrotum and testes, 
from I to 2 or 3 weeks are usally sufficient. Ordinary risks are 
seldom entitled to any partial disability following injuries involv- 
ing any of these parts. 

EFFECTS : An individual presenting a history of partial or 
complete rupture of the urethra, accidental in origin, is not con- 
sidered insurable for any kind of insurance unless a complete 
cure has resulted and no stricture has followed. Such a recovery 
is only ascertained after a careful examination by a competent 
physician. If recovery has been complete, all forms of insurance 
can be issued one to two years after that date. If one or both 
testes have been severely lacerated, all forms of insurance can 
be safely issued from three to six months after complete recovery, 
— provided no mental effect has been produced by the injury. 

CANCER OF THE PENIS OR TESTES 

INFORMATION: Cancer of the penis is usually found in 
males suffering with phimosis. It may be limited to the foreskin 
or involve the glans itself. When the glands of the groin are af- 
fected, an operation for the removal of a part of this organ re- 
quires the dissecting out of the affected glands. If a cancer in- 
volves one or both testes, it may be a sarcoma or carcinoma; the 
former results more frequently from injuries and is generally 
found in younger persons, while a carcinoma is more common 
in those past forty years of age. 



CANCER OF THE PENIS OR TESTES 179 

SIGNS AND SYAIPTOMS indicating a malignant growth 
involving the male sexual organs are the same as when found 
in other parts of the body; pain is a prominent symptom and is 
followed by swelHng and later ulceration. When a growth of this 
character involves the penis it may cause obstruction by pres- 
sure to the outflow of urine. If the testes are the parts affected, 
the epididymis is usually involved. When this condition results, 
there is a rapid increase in the size of the parts, with pain and a 
feeling of great weight to the organ. The glands of the groin 
are early affected. 

DIFFERENTIAL DIAGNOSIS: Benign Neoplasms are 
distinguished from a malignant tumor by the history. In the 
former growth is slow and remains encapsulated, the epididymis 
and inguinal glands are not involved and ulceration does not fol- 
low. Loss of weight is uncommon and pain is a rare symptom. 

Syphilitic Enlargement of the Testes occurs and the sw^elling is 
sometimes claimed to be accidental in origin. When this condi- 
tion is present, a history or evidence of syphilis having existed 
at one time can be elicited, and if this is not possible, treatment 
by mercury and iodides reduces the enlargement which is uni- 
form in size, causes no pain and show^s no evidence of a contusion 
or abrasion of the scrotum. 

Orchitis and Epididymitis due to venereal infection are fre- 
quently claimed as the result of accidents, and when this condi- 
tion is present, one or both testes may be involved, together with 
the epididymis. There is swelling with redness of the scrotum, 
great tenderness on pressure and constant pain which is worse 
when the parts are not supported. Venereal disease is positively 
eliminated by an examination of the urine which does not show 
shreds of mucus, if urethral disease is not present. In- addition 
one or both cords are tender when the enlargement is due to a 
pre-existing gonorrhea. 

Tuberculosis of the Testes may follow when this disease is 
present in some other part of the body. It may be a primary af- 
fection in either" the testicle or epididymis, usually the latter, and 
if only one testicle is involved the other one soon becomes af- 
fected. It is more common in young men and most frequently 
develops after an injury or some form of irritation which causes 
an inflammation of the testicle or epididymis. This disease is 
diagnosed by the nodular swellings which soon coalesce. Ten- 
derness is slight and little, if any, pain exists. 



180 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 



I 



HOUSE CONFINEMENT does not occur when cancer of 
the male sexual organs exists until an individual enters a hospital 
for an operation, and this time is seldom more than from 3 to 4 
weeks. 

TOTAL DISx\BILITY as the result of a cancer involving 
the male sexual organs, does not ensue until an operation is per- 
formed, when the individual is totally disabled until recovery 
takes place and this time is usually not more than from 3 to 6 
weeks. If healing does not follow, ulceration supervenes and 
total disability may persist until the disease becomes disseminated 
to other parts of the body and a fatal termination occurs. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if allowable by the poHcy after the termination of house confine- 
ment, may demand from i to 2 or 3 weeks in cases where house 
confinement has been short. 

EFFECTS : When cancer of the penis has existed, either 
affecting the skin or glans itself and an operation without much 
mutilation has followed, life or health insurance would not be 
issued to such a person until at least from three to five years had 
elapsed without any signs or symptoms referable to the disease, 
and even at the end of such a period it is questionable if these 
forms of insurance should be granted. Accident insurance can 
generally be safely issued from nine to twelve months after com- 
plete recovery. If the disease affects one testicle only and that is 
removed by operation and no recurrence takes place within three 
to five years, life or health insurance would be considered and is- 
sued by some companies. If both testes are involved and re- 
moved, insurance of all kinds would be denied such a person. 

EPIDIDYMITIS AND ORCHITIS 

INFORMATION: Epididymitis or inflammation of the epi- 
didymis is usually complicated with an inflammation of the tes- 
ticle and in many instances follows a urethral infection It may, 
however, be due to traumatism, such as the passing of an instru- 
ment through the urethra and fragments of calculi which are 
voided with the urine and rarely results from blows or straining 
in lifting heavy objects. Acute orchitis is an inflammation of one 
or both testes and may be due to traumatism, exposure, and as a 
complication to such diseases as mumps, rheumatism and certain 



PLATE II 



a 



b. 



V 




Xi 



C. 







Differential Diagnosis of Acute Enlargements of the Testis and Epidid.N mis 

(Eisendrath). 

a, Normal testis, b, Gonorrheal epididymitis and vas deferentitis. (.-. Acute oonoirheal epi- 
didymitis, deferentitis and acute gonorrheal hydrocele, d, Acute orchitis tollowing trauma of the 
testis, and the characteristic enlargement of the body of the testis (orchis) following mumps, 
and other infectious diseases. 



I 



EPIDIDYMITIS AND ORCHITIS 181 

infectious fevers, although in the vast majority of cases it is caused 
by gonorrheal infection. Chronic orchitis follows the acute form 
and is usually complicated with an inflammation of the epididymis. 

SIGNS AND SYMPTOMS of an acute epididymitis when 
due to an urethral infection may occur at any stage of the gonor- 
rhea, usually, however, it does not develop until after the second 
week of the disease and generally results in entire cessation of 
the discharge. Casper says twenty per cent, of all cases of gonor- 
rhea are attacked with epididymitis. This form of inflammation 
begins with a sense of weight in the testicle affected followed by 
pain which extends to the groin, extreme tenderness of the 
parts, anorexia, fainting attacks and swelHng of the epididymis 
and testicle. The cord is tender and painful and this extends and 
involves the groin, so that pressure over the cord in this region 
causes pain. 

If an orchitis results from a gonorrheal infection, the dis- 
charge ceases immediately and is followed by swelling, pain and 
tenderness in one or both testes. Systemic involvement is indi- 
cated by increased pulse, elevation of temperature, nausea, vomit- 
ing and prostration. If the inflammation is due to other causes 
than venereal disease, there is absence of venereal infection, 
swelling, pain and tenderness are present and almost invariably 
if the infection is caused by accidental injury, discoloration of the 
scrotum occurs and absence of pain over the cord in the groin is 
marked when this infection is not caused by gonorrhea. 

DIFFERENTIAL DIAGNOSIS: Syphilitic Enlargement of 
the Testes is always preceded by that disease, but frequently a 
history of this cannot be elicited. If the enlargement is specific 
in origin the swelling is limited to the body of the testicle, whose 
contour and shape are unchanged. This enlargement is very 
hard and when compressed does not cause nausea as results when 
compression is applied to a normal testicle. A hydrocele usually 
accompanies a syphilitic enlargement of this organ and one of the 
testes only is generally involved. 

Orchitis due to injury is differentiated from orchitis caused 
by venereal infection by the fact that in the former, evidence of 
traumatism to the scrotum is invariably present, such as abrasions 
or contusions which result in discoloration. Pressure on the cord 
as it enters the abdominal cavity shows the absence of tenderness 
when an orchitis is accidental in origin, while if caused by gonor- 
rhea, tenderness is always elicited. The urine is unaffected when 



182 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

this disease is caused by injury, but when due to an inflammation 
of the urethra, it contains shreds of floating mucus. The epi- 
didymis is generahy involved when an orchitis is caused by ve- 
nereal infection and this is not present Avhen it is accidental in 
origin. 

Tuberculous Disease of the Testicles should not be mistaken 
for an acute inflammation due to injury or to venereal infection, 
because if this condition is present it is important that such a fact 
be made known to the insurance company carrying the risk. 
When this disease involves the testes it is more frequent in young 
adults and almost invariably follows an infection in some other 
part of the body; one testicle is first involved and is soon fol- 
lowed by the disease in the other one or it may first appear in 
either epididymis and spread to the corresponding testicle. This 
condition when present in a quiescent state, is prone to develop 
quickly after a slight injury to these organs. The disease com- 
mences with a nodular swelling and these nodules soon coalesce 
and soften and this is followed by redness of the skin which in 
time ulcerates. A hydrocele of small dimensions not uncom- 
monly accompanies this condition. 

COMPLICATIONS: Urethral Disease in the majority of 
cases is the forerunner of an infection involving the testes and 
epididymis, and when such a disease exists, an insurance com- 
pany is not usually liable and will not pay for the resulting dis- 
ability. 

Parotiditis is often followed by involvement of the testes and 
in this condition generally both are inflamed, tender and painful. 
When inflammation of the testes complicates an attack of mumps, 
disability is prolonged one to two or three weeks; this time de- 
pending on the severity of the infection. 

HOUSE CONFINEMENT following an inflammation in- 
volving one or both testes and the corresponding epididymis, de- 
pends on the cause of the inflammation for the length of time' 
house confinement is necessary. When orchitis complicates an 
attack of gonorrhea, house confinement is made necessary at once 
and generally lasts from i to 2 or 3 weeks; this time depending 
on the treatment and the time at which it was commenced, the 
severity of the infection and the previous occupation of the in- 
dividual. If an orchitis follows a blow to the testes, house con- 
finement of from I to 2 weeks is necessary, and this time depends 
•on the severity of the blow, the occupation of the individual and 



PLATE 111 



% 



b. 



\ 





L\ 



^ 




DifFerential Diagnosis of Chronic Enlargements of the Testis and Epidid\inis 

(EisendrathX 

a. Syphilis of testis. This is one of the two forms in which SNphihs aftects the testis. In 
this variety both testis, that is the body of the testis Torchis), and epididymis are enlarged, h. 
Second variety of syphilitic affection of the testis. In this form the orchis or bod\ of the tes- 
tis is predominantly enlarged, giving rise to a large tumor, syphilitic orchitis, or sarcocele. c. 
Tuberculosis of the testis. This illustration shows the most frequent localization of tubercu- 
losis, especially in its early stages, involving especially the tail of thetestis and the vas deterens, 
in the form of a nodulated enlargement of the former, and a beaded one of the latter, d. 
Tumors of the testis This illustration shows how tumors, both benign and malignant, of the 
testis almost exclusivelv affects the bodv of the testis. 



EPIDIDYMITIS AND ORCHITIS 183 

the physical condition. A syphiUtic orchitis does not produce 
this form of disabiHty, although persons with such a condition fre- 
quently make claims for disability alleging that the sweUing is 
accidental in origin or due to exposure. If an orchitis follows an 
acute, specific fever, house confinement is prolonged from i to 
2 or 3 weeks and sometimes longer; this period depending on 
the physical condition of the individual at the time metastasis 
takes place, the severity of the infection and the occupation. If 
an epididymitis alone is present, house confinement of from 5 to 
10 days are generally enough for the individual to recover sufifi- 
ciently to return to some of the duties of the occupation. 

TOTAL DISABILITY is not often payable under an acci- 
dent, health or disability policy, when an orchitis results from a 
venereal disease. The majority of policies specifically eliminate 
indemnity for disability resulting from this disease, either directly 
or indirectly. If an orchitis follows an injury total disability of 
from 2 to 3 weeks is usually necessary in preferred risks. If the 
same condition is seen in ordinary risks, from 2 to 4 weeks of this 
form of disability are required. The same period of disability in 
both classes of risks also applies when this disease is the result 
of cold or exposure. Syphilitic enlargement does not cause total 
disability and even if it did, indemnity would seldom be payable 
under the terms of the poHcy. Total disability from a epididy- 
mitis alone which results from an accident, in preferred risks sel- 
dom requires more than i week, while those in the ordinary class 
demand from 10 to 14 davs. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the poHcy after the termination of house confine- 
ment in individuals suffering from an orchitis which is covered 
by the conditions of the policy, requires from i to 2 weeks in 
the majority of cases. When the inflammation is accidental in 
origin, from i to 2 or 3 weeks of partial disability are payable to 
preferred risks; this time depending on the severity of the injury, 
the degree of the resulting inflammation and the exact duties of 
the occupation. Ordinary risks are not often entitled to partial 
disability following an injury to these parts. 

EFFECTS : Individuals having suffered from an accident in- 
volving one or both testes and surrounding parts are insurable 
for all kinds of insurance from two to four months after complete 
recovery, provided a medical examination shows no evidence of 
a malignant growth as the result of the injury. If an orchitis or 



184 INJURIES AND DISEASES OF THE MADE SEXUAL ORGANS 

epididymitis is venereal in origin and is so stated on the applica- 
tion, an insurance company would question the advisability of is- 
suing any kind of a policy to such a person on account of the 
moral hazard involved. If the inflammation is syphilitic or tu- 
berculous in origin all forms of insurance would be denied such 
an individual. 

FISTULA IN ANO 

INFORMATION : A complete fistula in ano is an opening 
between the lower part of the rectum and the external surface 
of the body. It may be so small that gas only escapes or again 
it may be large enough for small particles of fecal matter to pass 
through. When the fistula opens externally and does not com- 
municate with the rectum or when it opens into the rectum and 
does not have an opening in the skin it is known as a blind fistula. 
A fecal fistula in this position in the majority of cases is tubercu- 
lous in origin, although it may be due to ulceration inside of the 
rectum, foreign bodies causing pressure, and traumatism. 




A. 
high i 
fistula. 



FIG. 37. — FISTULA IN ANO. (Fowler). 
Complete fistula, low in rectum; B, complete fistula, 
1 rectum; C, external blind fistula; D, internal blind 



SIGNS AND SYMPTOMS are sometimes present before 
the fistula ruptures externally when the cause has been ulceration 
from pressure, micro-organisms or other reasons. In such cases 
there is a constant, dull, aching pain with a desire to frequently 



FISTULA IN ANO 185 

defecate, a bearing down feeling and during the passage of feces 
this pain is intensified, unless the evacuations from the bowels are 
kept in a semi-hquid condition. If the fistula opens externally, 
there is a constant discharge of pus with a fecal odor. This dis- 
charge may persist for days or weeks and cause practically no 
disability, but in time the parts become excoriated and movement 
in the upright position becomes so painful that disability results. 

DIFFERENTIAL DIAGNOSIS: A Tuberculous Fistula 
must be differentiated from one accidental in origin and this is 
extremely hard in some cases. Usually, however, by careful ex- 
amination a tuberculous foci will be found in some part of the 
body. The opening in this form of fistula is generally surrounded 
by caulifiower-like granulation tissue, with an enlarged red and 
edematous area. 

COMPLICATIONS: When a fistula involving the rectum 
has been existing for weeks or months, the general physical con- 
dition of the individual is much deteriorated and if the fistula is 
tuberculous in origin, this disease is found in some part of the 
body, — usually the lungs. 

HOUSE CONFINEMENT does not result when a fistula 
is present until the physical health has gone so far below par or 
excoriations around the fistula have become so aggravated that 
confinement to bed is necessary for the treatment or radical cure 
of this condition. If an attempt is made to close the fistulous 
opening by medical mxcans, house confinement may last from i 
to 2 or 3 weeks; this time depending on the cause of the fistula, 
its extent and the length of time it has been in existence. AMien 
house confinement results on account of an operation being un- 
dertaken for its cure, it generally lasts from 3 to 6 weeks, this 
period depending on the above enumerated conditions. 

TOTAL DISABILITY does not ensue when this condition 
is present until it becomes so aggravated that further attention 
to business is impossible, or its cure is attempted by medical or 
surgical means. In the former total disability is uncertain and 
may last from i to 2 or 4 weeks, and when an operation is per- 
formed total disability does not last much longer than the period 
of house confinement; this time generally being from 3 to 4 or 6 
weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is not required in cases in which a cure is attempted by 



186 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

medical means, but when an operation is performed from i to 2 
weeks of this form of disabihty may be necessary in some cases. 
EFFECTS : If a history of a recent fistula exists, insurance 
companies look with disfavor on such applications and few com- 
panies will accept individuals for life or health insurance until at 
least two years have elapsed after the complete healing and cure 
of the fistula. If the fistulous opening has been 'tuberculous or 
there is any possibility of such a condition having existed, such 
a person would be uninsurable for any kind of a policy. Accident 
insurance can generally be issued to individuals having suffered 
with a fistula which is. not tuberculous in character, from two to 
four months after complete closure of the opening. 

GONORRHEA 

SYXOXY]\IS: Specific urethritis; venereal catarrh; clap; 
tripper. 

IXFOR]\IATIOX : Gonorrhea is an acute inflammation of 
the genital mucous membrane, of venereal origin, due to the 
deposition and multiplication of gonococci in the cells of the 
membrane and a mixed infection with the cocci of suppuration 
(Da Costa). This disease being venereal in origin, indemnity is 
not often payable under an accident or health policy when dis- 
abihty results and very few individuals attempt to make a claim 
alleging such a cause. 

SIGXS AXD SY:\IPT0^IS are well known; among the 
more common are swelling of the penis with a discharge from the 
urethra. This discharge contains the specific micro-organism 
causing the disease. The period of incubation varies from a few 
hours to one to two weeks. 

C0:MPLICATI0XS; Gonorrheal Arthritis or gonorrheal 
rheumatism is one of the frequent complications and must be dif- 
ferentiated from articular rheumatism. It occurs more frequentlv 
in the male than in the female and most often involves the joints 
of the knees, next in frequency are the ankles and the joints of 
the fingers and hands. When an articulation becomes affected, 
the attack is sudden in onset and is followed by pain which be- 
comes very severe, swelling with fluid in the joint and moderate 
fever which soon subsides. Gonorrheal arthritis is of shorter 
duration and of less intensity than articular rheumatism and does 
not yield promptly to anti-rheumatic treatment. 



GONORRHEA 187 

Orchitis and Epididyiuitis are frequent complications of this 
disease when in the decHning stage. The differential diagnosis 
between disease and accident to these organs is discussed under 
Orchitis and Epididymitis. 

Enlargement of the Glands of the Groin or buboes are fre- 
quent during an attack of this disease. The glands on one or 
both sides become enlarged, painful and tender. If suppuration 
ensues, redness appears, to be followed by softening and break- 
ing down of the skin covering the glands with a discharge of pus. 
Usually, however, when this complication arises disability does 
not ensue until suppuration follows, and an operation becomes 
necessary, then house confinement with total disability for some 
time is required. 

Gonorrheal Ophthalmia is sometimes a complication of ve- 
nereal diseases and when present total disability ensues in all 
cases and generally the loss of sight in one or both eyes results. 
In such cases it would be necessary to secure a culture from the 
discharge, in order to prove positively that the loss of sight was 
gonorrheal in origin, when an insurance company would probably 
not be liable for the temporary or permanent disability. 

Chancroid is frequently seen in conjunction with gonorrhea 
and usually results from contact during sexual intercourse. It 
is a local sore and yields to local treatment and when present it 
does not prolong disability, not even producing it, except in cases 
when it becomes phagedenic. 

Chancre often complicates gonorrhea, but as it represents a 
distinct and systemic disease which would not often be covered 
by an insurance policy, its consideration is unimportant. 

HOUSE CONFINEMENT does not exist in this disease 
unless some of the complications follow, when this period is gov- 
erned by the character of the complication and its severity. 

TOTAL DISABILITY is not often payable under an acci- 
dent or health policy to an individual suffering from this disease, 
even though a compHcation is existing. Claims are frequently 
made when one of the complications of gonorrhea is present, with 
the idea or intention of getting indemnity. If a proper medical 
examination is made, however, a physician is able to determine 
that the primary cause of disability is venereal in origin and 
therefore indemnitv is not usually payable. 

PARTIAL INDEMNITY FOR TOTAL DISAlVi 1 .irv 



188 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

if payable by the policy after the termination of house confine- 
ment, should very rarely be paid in any case of this disease. 

EFFECTS : Although all insurance companies ask the ques- 
tion if any venereal disease has been suffered, the answer is in- 
variably ''no" even though the majority of males have been at- 
tacked by this disease, and especially during the period from 
eighteen to thirty years of age. If it is known that such a condi- 
tion was present and pronounced cured by a competent physi- 
cian, life or health insurance could be safely written from three 
to six months after complete recovery. Accident insurance in 
such cases would be granted from one to two months after re- 
covery was said to be complete. The moral hazard in individuals 
who have suffered from this condition is always to be considered 
in the granting of any form of insurance and the various insur- 
ance companies have different wa3^s of treating cases with a his- 
tory of this disease; some being very strict in regard to the moral 
hazard, while others are more lax. 

HEMORRHOIDS 

SYNONYMS: Piles; bleeding piles; skin tabs. 

INFORMATION : Hemorrhoids are varicose tumors of 
the rectum and may be external when they originate without the 
external sphincter and internal when the source of origin is with- 
in this sphincter muscle. External hemorrhoids are frequently 
seen and seldom cause disability, unless by irritation they ulcerate 
and form large masses of broken down tissue. Internal hemor- 
rhoids that are covered by mucous membrane are much easier 
lacerated and torn and therefore more prone to cause disabiHty. 
Either variety may be due to disease or the passing of hard 
masses of fecal matter and sometimes this condition results from 
traumatism, such as kicks or a fall in which the body alights 
astride of some hard fixed object. 

SIGNS AND SYMPTOMS: External hemorrhoids are 
small protuberances around the anus and are always covered by 
skin. If ulceration results, an open sore is present and is accom- 
panied by pain and little, if any, bleeding. Itching is a common 
symptom of this condition and is more pronounced at night. In- 
ternal hemorrhoids which do not protrude beyond the sphincter 
muscle seldom show any symptoms until a prolapse occurs, when 
there is itching, pain and tenderness, and if rupture follows, bleed- 



HEMORRHOIDS 



18& 



ing is the result. They frequently ulcerate and either produce 
disability at once or require an operation for a cure. 




Fig-. 39. — Ulcerating- and prolapsed internal hemorrhoids. (7',erg- 



DIFFERENTIAL DIAGNOSIS is important from an in- 
surance point of view, between an old standing hemorrhoid 
which may be claimed as due to an injury and a recent one which 
is the result of traumatism. When a hemorrhoid has been pres- 
ent for some time and becomes acutely inflamed from the pass- 
age over it of fecal matter it may appear as the result of an injury, 
but in such cases an examination will show that the small tumor 
mass is composed of fibrous tissue, while a recent hemorrhoid 
as the result of accident is tense, red and inllamed, is tilled with 
blood, tender, painful and contains no fibrous tissue. 

HOUSE CONFINEINIENT does not result in individuals 
sufiferinof with hemorrhoids until the ccMulitiiMi bocomos acutely 



190 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

inflamed. AMien this follows, house confinement of 3 to 7 days 
may be necessary before the inflammatory condition is relieved. 
If a hemorrhoid results from an accidental injury, house confine- 
ment of I to 2 weeks is often necessary before the condition is 
sufficiently recovered for the individual to resume a part of his 
occupation. If an operation is performed, house confinement of 
I to 2 weeks is necessary. 

TOTAL DISABILITY if caused by an acute inflammatory 
action involving old standing hemorrhoids, lasts from 3 to 7 
days, at the end of which time the inflammation has sufficiently 
subsided to allow at least a partial return to the occupation. If 
traumatism causes this condition, total disability of i to 2 and 
sometimes 3 weeks is necessary and this is especially true when 
the occupation of the individual necessitates the upright posi- 
tion with more or less walking. Operative measures involving 
the removal of the abnormal condition, requires from I to 3 
weeks before' the occupation can be resumed. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is not necessary vrhen the condition is an old standing one. 
If the disability is the result of accidental injury, partial disability 
of I to 2 weeks may be necessary; this time depending on the 
severity of the injury and the exact duties of the occupation. 

EFFECTS: Individuals suiTering from hemorrhoids that 
have a history of having been acutely inflamed a number of times 
are not insurable for health insurance without a waiver being 
placed on the policy eliminating indemnity for this source of dis- 
ability. Life or accident insm-ance, however, could be safely is- 
sued to such persons as soon as recovery becomes complete. 

HYDROCELE AND HEMATOCELE 

INFORMATION : A hydrocele is a collection of fluid in the 
tunica vaginalis testis and is usually of unknown origin, although 
it is often claimed that such a condition results from traumatism. 
Prominent surgeons, however, seldom see more than one or two 
cases of hydrocele of traumatic origin during their period of prac- 
tice, showing that this collection of fluid is rarely accidental in 
origin. A hematocele is generally a collection of blood in an old 
hydrocele and most frequently follows a puncture of the hydro- 
cele bv a trocar for its cure. 



I 



HYDROCELE AND HEMATOCELE 



191 



SIGNS AND SYMPTOMS: When a hydrocele develops it 
does so very gradually, causing a swelling which contains a straw- 
colored fluid. This swelling is pyriform in shape and translucent, 
fluctuates and the testicle is found at the lower and back part of 




Fig-. 40. — Hydrocele. (Keen and White). 



the sac. As the swelling enlarges, the scrotum becomes tense 
and of a reddish color. Pain is generally absent and a feeling of 
weight is complained of unless the parts are supported by a sus- 
pensory bandage. 

DIFFERENTIAL DIAGNOSIS : Hydrocele as the result of 
an accident would closely follow the date of injury and in addition 
there would be discoloration of the scrotum, with pain and ten- 
derness. If a true history can be obtained it would be found that 
no swelHng existed before the accident and at the time the injury 
occurred, pain of a nauseating character would be present. 

COMPLICATIONS : Hematocele may complicate a hydro- 
cele and when this condition supervenes there is a pre-existing 
hydrocele which has been injured by external means, or a punc- 
ture for the cure of this condition ruptures a small blood vessel 
and the sac fills up with blood instead of a straw-colored fluid. 

HOUSE CONFINEMENT does not exist when a hydro- 
cele is present, unless the individual sufl^ers an injury which in- 
volves this swelling or voluntarily undergoes an operation for 
the cure of the condition. If a hematocele is present, house con- 
finement of I to 2 weeks may be necessary: this time depending* 
on the occupation of the individual and the method of treatment. 

TOTAL DISABILITY does not occur in cases of hydrocele 
which have been of lone standing, but if this eulareeuicnt is the 



192 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

result of accidental injury, total disability of 2 to 4 weeks may be 
necessary on account of the external injury to the scrotum and 
testes. AMien an individual suffering from this condition under- 
goes an operation for its cure, total disabiUty depends on the 
method of treatment. If a cure by puncture only is attempted, 
from 2 to 3 days are generally sufhcient, but if the sac is removed 
by a cutting operation, from 2 to 4 weeks are required for com- 
plete healing. An accident or disability policy would not cover 
disability when this condition has existed for some time and an 
operation is voluntarilv undergone. 

PARTIAL IXDEMXITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is never allowable in cases suffering with a hydrocele or 
hematocele, unless an operation has been performed, when i to 2 
weeks may be necessary in some cases. 

PARTIAL DISABILITY of i to 2 weeks may sometimes 
be required when a hydrocele or hematocele develops from an 
accidental injury and total disability has immediately ensued. 

EFFECTS : Individuals suftering from a hydrocele or hem- 
atocele are usually considered insurable for all kinds of insurance 
without regard to this condition. If an operation is performed 
insurance would hardly be granted until one to two months after 
complete recovery. 

ISCHIO-RECTAL ABSCESS 

INFOR^IATIOX : An ischio-rectal abscess is a collection 
of pus in the ischio-rectal fossa and is said to be due to cold or 
exposure, the passage of hard fecal masses which cause ulcera- 
tion and this is followed by infection which extends and involves 
the fat in this fossa, ulcerated hemorrhoids and by external trau- 
matism, such as kicks or blows. An abscess in this situation is 
often tuberculous in origin and when existing, the differential 
diagnosis between an abscess caused by pyogenic bacteria must 
be made from one caused bv tubercle bacilli and mixed infection. 

SIGXS AND SY^IPTO^IS begin with a swelHng which 
soon becomes hard and brawny. Slight discoloration of the skin 
appears and this takes on a purplish hue. Pain is hardly notice- 
able at first, but later becomes severe and especially when a bowel 
movement occurs. Tenderness over the fossa involved, with a 
hectic temperature are present. Unless an ischio-rectal abscess 
is opened externally, it ulcerates at the point of least resistance 



il 



ISCHIO-RECTAL ABSCESS 193 

and evacuates itself into the rectum. This results in a fistula and 
prolongation of disability. 

DIFFERENTIAL DIAGNOSIS between ischio-rectal ab- 
scess caused by tubercle bacilli and pyogenic bacteria is usually 
not made until the abscess is evacuated and the microscope 
shows the presence of tubercle bacilli in the pus. A tuberculous 
abscess may have cauliflower-Hke growths around the orifice and 
requires a more extended time in healing. This disease when 
existing is usually found involving some other part of the body. 

COMPLICATIONS: A Fistula always follows an ischio- 
rectal abscess unless an external opening is made into this fossa 
for the purpose of evacuating the pus before nature makes the 
opening into the rectum. When the abscess follows an ulcera- 
tion of the rectum, a fistula is already existing and if this com- 
phcation is present disability is greatly prolonged. 

HOUSE CONFINEMENT of 2 to 4 weeks is usually neces- 
sary when the ischio-rectal fat becomes infected and an abscess 
results. 

TOTAL DISABILITY in all classes of risks lasts from 3 
to 6 or 8 weeks when this form of abscess is present; this time 
depending on the duties of the occupation of the individual and 
the method of treatment. If an abscess in this situation is opened 
early and especially if no fistula exists, total disability is short- 
ened. When a rectal fistula complicates the case and an opera- 
tion is necessary for closing the orifice between the bowel and 
the fossa, total disability of from 6 to 8 or 10 weeks is often 
required. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment sometimes requires from 2 to 4 or 6 weeks; this time being 
demanded when the period of house confinement is short. If 
the abscess results from traumatism, partial disability of from 2 
to 4 v/eeks is frequently necessary. 

EFFECTS : Individuals with a historv of havino" suffered 
from an ischio-rectal abscess in which the cause is supposed to 
be tuberculous in origin, are uninsurable for any kind of a policv. 
When the abscess results from infection through the bowel or bv 
external traumatism, all forms of insurance can be safelv written 
from three to six months after complete recoverv. 



194 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

ENLARGEMENT OF THE PROSTATE GLAND 

SYNONY]\IS: Acute prostatitis; chronic prostatitis. 

INEORMATION: Enlargement of the prostate gland may 
be due to an acute or chronic inflammation. Acute prostatitis 
most frequently follows or complicates an attack of gonorrhea. 
It may, however, result from the extension of an inflammation 
involving adjacent parts, infection from the passage of stone from 
the bladder or instruments through the urethra; it also accom- 



SSM'nfAL veSICUi 



UffETHRA 




EJACULATOP.Y DUCT 



Fig. 41. — Prostrate gland and appendages. (Campbell). 

panics certain infectious fevers. Chronic prostatitis is more com- 
monly the result of gonorrheal infection. It may, however, be 
due to stone in the bladder, stricture of the urethra and in men 
fifty years of age or over, it is usually a chronic condition. 

SIGNS AND SYMPTOMS of acute or chronic prostatitis 
follow enlargement of this gland. There is frequent micturition, 
pain which is complained of in the region of the neck of the blad- 
der, tenderness in the perineum and sometimes bulging of this 
part of the body. If a finger is introduced into the rectum, the 
enlarged gland is easily detected and pressure causes increased 
pain and sometimes a discharge of prostatic fluid. A chronic en- 
largement results in residual urine and often in chronic C3^stitis. 

COMPLICATIONS : Chronic Cystitis is the most frequent 
complication resulting from an enlargement of this gland and is 
usually found in men past fifty years of age. When the gland be- 
comes so enlarged that urination is greatly interfered with, the 
use of a catheter becomes necessary. Enlargement of the pros- 
tate gland is often sarcomatous and if this complication exists it 
is generally not diagnosed until the gland is removed, when the 
microscope shows the true cause of the enlargement. 



INJURY TO THE MALE URETHRA 195 

HOUSE CONFINEMENT in an attack of acute prostatitis 
lasts from i to 2 or 3 weeks. When the condition is chronic, 
house confinement does not ensue unless an operation is per- 
formed for the removal of all or part of the gland, or a complica- 
tion arises. If an operation is undergone the length of house 
confinement depends on the method of operating. When a peri- 
neal incision is made house confinement of from 3 to 5 weeks is 
usually sufiicient. If the gland is removed by the suprapubic 
method, house confinement of from 4 to 6 or 8 weeks is neces- 
sary. 

TOTAL DISABILITY of 2 to 3 weeks is usually required 
in an acute attack of prostatitis; this time is usually not payable 
if the disease is venereal in origin. W^hen a chronic enlargement 
of the gland exists and an acute inflammation supervenes caus- 
ing house confinement and an operation, total disability of from 
4 to 6 weeks is necessary when the gland is removed by the peri- 
neal route. If removal is done through the abdominal wall total 
disability lasts from 6 to 8 or 10 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment may require from i to 3 or 4 weeks; this time depending on 
the physical condition of the individual after the termination of 
house confinement and the exact duties of the occupation. 

EFFECTS: An acute inflammation of this gland has no 
effect on the insurabiHty of an individual for any kind of insur- 
ance and as soon as recovery is complete, all forms of insurance 
can be safely issued. When an operation is performed for its re- 
moval in old or middle-aged men, life or health insurance can 
usually be safely granted from three to six months after com- 
plete recovery, provided the enlargement has not been malignant 
in (Character. Accident insurance in such cases can be issued as 
soon as recovery is complete. 

INJURY TO THE MALE URETHRA 

INFORMATION: Rupture of the male urethra is a condi- 
tion in which the outlet from the bladder is either partially or 
completely severed. When the rupture occurs it is almost al- 
ways found in the perineum and is due to pressure of the 
urethra against a solid body, such as the pubes or when a fall is 
sustained and the bodv aliehts astride a rieid substance. 



196 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 



SIGNS AND SY^IPTO:^IS follow immediately after the in- 
jury has been sustained. Pain is first complained of and this is 
aggravated by movement or attempts to urinate and when this 
function is accomplished blood precedes the passage of urine. 

Retention of urine frequently fol- 
lows such an injury. Hemor- 
rhage occurs, some of the blood 
entering the bladder, but in the 
majority of cases it is retained in 
the perineum and this causes 
bulging and later discoloration. 
This blood sometimes extends 
into and involves the scrotum, re- 
sulting in swelling and discolora- 
tion. If an operation is not per- 
formed early, extravasation of 
urine into the perineal tissues oc- 
curs, causing edema and later 
sloughing of the parts. 

COAIPLICATIONS : Cys- 
titis frequently follows a rupture 
of the urethra. If this complica- 




FIG. 42.— RUPTURE OF THE MALE 

URETHRA AND BLADDER. (Keen's 

Surgerj') 

RU, rupture of urethra associated with 
extravasation of urine into the scrotum |-ion CUSUCS, hoWCVCr, the len2:th 
(S) and penis (p) ; B, bladder. The o 

arrow upon the anterior wall indicates ^f disabilitv is Uuiufluenced, for 
an extraperitoneal rupture of the blad- • ' 

der with extravasation of urine into the ^|-^ reaSOU that the COmoHcatioU 
extraperitoneal cellular tissues around r 

the bladder and between the peritoneum ncnalK' rIico-r>-n<=koi-c 'h(^-('rM-/=» rf^r^m^r^ 
and anterior abdominal wall (EPS). ^^SUaii} QlSappCai S DCIOrC reCO\ 
The arrow situated upon the posterior p..,, folrf^o. rklarp 
wall and the fundus of the bladder in- ^^ } Ldivcs |Jid.L,c. 

fi1ZlrZlelf'"'!e.°' "S^ 'Ve'^rTe. Abscess of the Perineum is a 

fSS^lT .T:"L,n?'es'capt.'"'etS?i commoii Complication following 

the coils of intestine into the general , r ,i ii i • 

peritoneal cavity (PC). a rupturc ot the urcthra and is 

due to the extravasation of blood 
and urine into the soft tissues in this situation. When it occurs 
disability is not often prolonged, as this complication also disap- 
pears before recovery from the rupture of the urethra is com- 
plete. 

HOUSE COXFIXEMEXT depends on the degree of in- 
jury to the urethra. If a partial rupture has occurred and an 
early operation is performed, house confinement of from 2 to 3 
or 4 weeks is usualh^ sufhcient. When the urethra is badly torn 
and lacerated and requires an extensive operation for its repair, 
house confinement of from 4 to 6 or 8 weeks is often demanded. 



URETHRITIS 197 

TOTAL DISABILITY following a partial rupture of the 
urethra lasts from 3 to 6 or 8 weeks; this time depending on the 
extent of the laceration, the rapidity with which healing takes 
place and the occupation of the individual. When the laceration 
has been severe total disability of from 8 to 12 or 16 weeks is 
often necessary; this time also depending on the above named 
conditions. 

PARTIAL DISABILITY generally follows an accident of 
this character and the length of time depends on the severity of 
the injury and the occupation of the individual. A slight injury 
with only a partial rupture of the urethra may require from i to 
3 or 6 weeks of this form of disability. If a severe injury has been 
sustained, partial disabihty of from 2 to 3 or 4 months is some- 
times necessary. 

EFFECTS: Individuals having suffered from a partial or 
complete rupture of the urethra are thereafter not considered 
insurable for life or health insurance until five to ten years have 
elapsed and no difficulty in urinating is experienced. Accident 
insurance, however, can usually be safely issued from three to six 
months after a complete recovery. 

URETHRITIS 

INFORMATION: Urethritis or inflammation of the 
urethra may be due to a number of causes; the most frequent, 
however, being gonorrhea. It may also be due to any form of 
irritation appHed to the urethra, or external traumatism and is 
sometimes found in connection with gout, rheumatism or tuber- 
culosis. If an inflammation of this portion of the body occurs it 
is highly important to an insurance company to eliminate ve- 
nereal disease, for the reason that the majority of companies will 
not pay indemnity under an accident or health policy when dis- 
ability is the result of venereal infection. 

SIGNS AND SYMPTOMS: A discharge is generally the 
first sign of a urethritis unless the infection is accidental in origin, 
when pain would precede the discharge. Pain is made worse by 
attempting to urinate, swelling of the penis occurs and complica- 
tions resulting from the extension of the infection may follow. 

DIFFERENTIAL DIAGNOSIS between a' urethritis 
which is venereal in origin and a nonspecific one is important. 
.\ simple urethritis may result from traumatism aiul produce a 



P9TTT 



198 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

discharge, but the use of the microscope will serve to quickly 
ehminate the gonoccocus and show that the disease is not ve- 
nereal in origin. 

COMPLICATIONS often follow an inflammation of this 
part of the body and are described under Gonorrhea. 

HOUSE CONFINEMENT depends on the cause of the 
urethritis. If venereal in origin or due to simple infection, house 
confinement seldom exists. If the inflammation follows an acci- 
dental injury, house confinement is described under Injury to 
the Male Urethra. 

TOTAL DISABILITY never occurs when a urethritis is 
the result of a simple infection or venereal in origin, unless the 
disease is complicated by one of the numerous complications 
which result from the extension of this inflammation. If the 
urethritis is the result of an accidental injury, the length of total 
disability is described under Rupture of the Male Urethra. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
following an inflammation of the urethra is sometimes demanded, 
but claims alleging such a cause are not often received, for the 
reason that this inflammation is almost invariably venereal in 
origin. If the urethritis follows an injury to the urethra, partial 
disability is explained under Rupture of the Male Urethra. 

EFFECTS : If an individual has suffered from a urethritis, 
whether venereal in origin or not, all forms of insurance could be 
safely issued from three to six months after complete recovery, 
provided the moral hazard is taken into consideration. When a 
history of this disease is elicited a number of years previous, it is 
important to ascertain before issuing a life or health policy if a 
stricture exists, and if so, its extent and severity. Accident in- 
surance would be issued as soon as recovery becomes complete, 
provided the moral hazard permits. 

VARICOCELE 

INFORMATION: A varicocele is an enlargement of the 
veins of the spermatic cord and is said to be caused by occupa- 
tions that require the upright position, persistent constipation 
and is rarely accidental in origin, in such cases being due to a 
strain. It is more common on the left than on the right side. 

SIGNS AND SYMPTOMS: When a varicocele exists, an 
irregular swelling is found on the posterior surface of the' testicle 



VARICOCELE 199 

and this extends up the cord. It has been described as feehng 
Hke a "bag of earth-worms." This swelhng becomes lessened 
when the individual is in a recumbent position, but increases 
when the upright position is assumed. SHght pain is sometimes 
complained of and in some cases a feeling of weight and soreness 
is present. Mental symptoms such as depression and hypochon- 
dria not uncommonly accompany this condition. 

DIFFERENTIAL DIAGNOSIS: Epididymitis may some- 
times be mistaken for this enlargement, but in the former there 
is severe pain and swelling of the testicle follows, while in a vari- 
cocele the condition is chronic and the testicle if involved at all, 
becomes atrophied. 

Hernia of the Omentum when slight may be confused with a 
varicocele, but in this condition when the recumbent position is 
resumed the hernia may disappear entirely unless the protrusion 
has become adherent. Examination of the ring through which 
the cord passes would serve to make the diagnosis clear between 
a hernia and varicocele. 

HOUSE CONFINEMENT does not exist when a varico- 
cele is present unless the condition becomes acutely inflamed by 
injury or an operation is performed for its removal. If an injury 
is sustained and an inflammation follows, house confinement of 
I to 2 weeks may be necessary. If an operation is performed for 
the cure of this condition, from i to 2 or 3 weeks of house con- 
finement are required; this time depending on the method of 
operation and the rapidity with which the tissues heal. 

TOTAL DISABILITY is never present when a varicocele 
exists unless an injury causes an acute inflammation, or an oper- 
ation for a radical cure is attempted. When an injury occurs, 
total disabihty of from i to 2 or 3 weeks may be required. If 
an operation is performed for the removal of the enlarged veins, 
total disabihty may last from 2 to 4 weeks, but this period would 
not be covered by an accident or disability policy if the operation 
was voluntarily undergone by the individual. If the veins had 
become inflamed for an}^ reason other than venereal and disability 
resulted, an insurance company would be liable under an accident 
or health policy. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is seldom deserved in this condition unless an operation has been 
undergone and recovery is slow, when from i to 3 weeks are 
usually sufficient. 



200 INJURIES AND DISEASES OF THE MALE SEXUAL ORGANS 

EFFECTS : Individuals suffering with a slight varicocele 
that has not caused any mental impairment are generally consid- 
ered insurable for all kinds of insurance without regard to this con- 
dition. If the veins are greatly enlarged, it is questionable if any 
form of insurance would be issued to such a person. When an 
operation has been performed for the cure of this condition, all 
forms of insurance can be safely granted from one to two months 
after complete recovery. 



CHAPTER X 

ACCIDENTS AND DISEASES OF THE UPPER EXTREMITY 

PART I 

INJURIES TO THE SOFT TISSUES 

ABRASIONS AND CONTUSIONS OF THE SHOULDER 

AND ARM 

INFORMATION: Abrasions located on the shoulder are 
usually sustained in conjunction with more violent injuries, and 
rarely cause disability unless complicated. Contusions occurring 
to this part of the body are caused by heavy blows received when 
in the upright position or when the body falls and the shoulder 
violently strikes the ground. Severe contusions are generally ac- 
companied by sprains, fractures or dislocations involving the 
shoulder joint. 

SIGNS AND SYMPTOMS: Abrasions are distinguished 
by the skin being broken and abraded in a number of places, and 
this is followed by bleeding and scabbing. Contusions produce 
swelling of the soft tissues surrounding the joint with more or less 
discoloration. Pain, tenderness and lessened use of the articula- 
tion follows severe contusions. 

COMPLICATIONS are usual in severe contusions to this 
part of the body and consist of sprains, dislocations and fractures 
of some of the bones entering into the formation of the shoulder 
joint. When these comphcations exist, the period of disability is 
determined according to the complication; it being the most se- 
vere injury. 

TOTAL DISABILITY should never be allowed for uncom- 
plicated abrasions or contusions involving this part of the body, 
as they do not produce this form of disability in preferred risks. 
Ordinary risks are sometimes totally disabled from 2 to 5 days 
following a very severe contusion of the shoulder. 

201 



202 INJURIES TO THE SOFT PARTS OF THE UPPER EXTREMITY 

PARTIAL DISABILITY is not payable to ordinary risks af- 
ter such an injury, but preferred risks may occasionally claim 
from I to 2 weeks of this disability. 

EFFECTS : These injuries recover quickly and the individual 
is insurable for any form of policy as soon as evidence of the ac- 
cident disappears. 

INCISIONS AND LACERATIONS OF THE SHOULDER 

AND ARM 

INFORMATION : Superficial incised wounds involving the 
shoulder or arm are due to contact with sharp instruments which 
cut the superficial tissues onl3\ If the incision is deep and severs 
some of the muscles or the blood vessels and nerves that are found 
on the under and inner surface of the arm, total disability is 
greatly prolonged and permanent impairment of the function of 
the arm can result. Lacerated wounds usually involve the skin 
and underlying tissues of the shoulder and arm and are produced 
by any instrument with a blunt edge which partly cuts and lacer- 
ates the tissues with which it comes in contact. These wounds 
are often the result of injuries sustained in mills by contact with 
machinery. 

SIGNS AND SYMPTOMS following incised or lacerated 
wounds are hemorrhage, separation of the wound edges which 
may be clearly cut or ragged, pain, swelling, and if some of the 
muscles have been severed, inability to move the arm in the direc- 
tion controlled by the muscles involved. If a nerve has been cut 
the same result ensues, together with loss of sensation. Some- 
times the shoulder joint is opened by an incised wound and this 
is followed by infection, suppuration and limited movement in the 
joint. 

CO]\IPLICATIONS: Infection is usual in lacerated wounds 
and almost invariably occurs in an incised wound which pene- 
trates the joint cavity. 

TOTAL DISABILITY following superficial or lacerated 
wounds involving the shoulder and arm in preferred risks may re- 
quire from 3 to 7 days. In the same class, when the incision or 
laceration has been extensive, total disability lasts from 5 to lO 
days. This time is increased about i week if infection occurs. 
Ordinary risks are not totally disabled from superficial incised or 
lacerated wounds unless a great number of them exist, when i 



PUNCTURED WOUNDS OF THE SHOULDER AND ARM 203 

week is generally sufficient. If the incision or laceration is exten- 
sive, such as produced by machinery, ordinary risks are usually 
totally disabled from 2 to 4 weeks, as infection is almost always 
present in these cases. When an operation is necessary for sutur- 
ing the severed ends of the muscles together or tying important 
blood vessels, total disability in all classes of risks lasts from 2 to 
4 weeks. If an important nerve of the arm is injured or divided, 
total disability is very uncertain and depends on the exact duties 
of the occupation, the physical condition of the individual and the 
rapidity with which repair of the nerve is accomplished by nature. 
Joint injuries resulting from deep incised wounds cause total dis- 
ability of 3 to 6 weeks and sometimes longer in all classes of risks. 

PARTIAL DISABILITY of i to 2 weeks is frequently de- 
served by preferred risks following deep incised or lacerated 
wounds of the arm or shoulder when the period of total disability 
has been short. Ordinary risks are not often entitled to any par- 
tial disability after this class of injuries. Incised or lacerated 
wounds that enter the shoulder joint or divide some of the im- 
portant nerves of the arm may be followed by partial disability of 
2 to 4 weeks; this depending, however, on the occupation, the lo- 
cation of the injury and the period of total disability which pre- 
cedes it. 

EFFECTS : Incised or lacerated wounds of the arm that are 
not sufficiently deep to badly injure the muscle, enter the 
shoulder joint or sever any of the blood vessels and nerves cause 
no permanent impairment of the function of the arm or shoulder, 
but leave scars which are covered by clothing. If permanent de- 
formity or disabihty results from an injury of this character and 
is sufficiently severe to impair the functions of the arm and 
shoulder the individual is not insurable for accident insurance at 
any time, although a Hfe or health policy may be safely written. 

PUNCTURED WOUNDS OF THE SHOULDER AND AR:M 

INFORMATION: Punctured wounds involving the 
shoulder or arm result from any sharp-pointed instrument w liich 
is driven into this part of the body by force. Sometimes when 
the puncture is made by small instruments, such as needles, 
spHnters, etc., a piece is broken off and remains in the tissues. 
Punctured wounds resulting from missiles propelled by gun pow- 
der cause widespread damage, involving the nuiscles and nerves. 



204 INJURIES TO THE SOFT PARTS OF THE UPPER EXTREMITY 

and if a bone is struck, it is usually badly broken and splintered- 
Punctured wounds as the result of bullets generally push aside 
tendons and large arteries, but often wound the walls of the artery 
and later an aneurysm results or a secondary hemorrhage occurs. 

SIGNS AND SYMPTOMS: Punctured wounds that are 
made by any kind of an instrument or missile are apparent to the 
naked eye and are followed by bleeding which is shght, unless an 
important blood vessel has been wounded, when the hemorrhage 
is severe. There is pain, swelKng, and inflammation surroundings 
the puncture, and when made by a fire-arm which is held close 
to the body, powder marks are evident. This class of injuries due 
to fire-arms usually show the point of entrance smaller than the 
missile itself and the point of exit larger and ragged, with the sur- 
rounding tissues torn and contused. If the puncture has been due 
to a bullet which enters the shoulder joint or splinters the bones 
of the shoulder or arm, evidence of a fractured bone is apparent. 
Pain is shght when the puncture has been small, but when due 
to gunshot injuries it is severe and becomes much worse when 
complicated by an injury to the joint or a fracture of some of 
the bones. Infection almost invariably follows this class of in- 
juries when suppuration ensues and greatly prolongs disability. 

COMPLICATIONS : Infection, Erysipelas or Tetanus may 
complicate a punctured wound, when disability will be prolonged 
according to the time the complication requires for recovery. 

TOTAL DISABILITY is seldom payable to any class of 
risks when the puncture is made by a sharp-pointed instrument 
and involves the soft tissues of the shoulder or arm and is not fol- 
lowed by infection or other complication. If the puncture is due 
to a gunshot injury and involves the soft tissues only, total dis- 
ability lasts from i to 2 weeks in preferred and from 2 to 3 weeks 
in ordinary risks. Punctured wounds due to gunshot injuries 
which fracture the bones or enter the joints, produce total disa- 
bility of 6 to 10 weeks in all classes of risks. If an operation is 
necessary following this kind of injury, total disability may last 
from 6 to 12 weeks. Suppuration in any of the above wounds 
generally prolongs disability from i to 3 weeks, depending on the 
severity of the infection, the depth of the wound and the location. 

PARTIAL DISABILITY is not deserved in any class of 
risks following ordinary, uncomplicated punctured wounds involv- 
ing the soft tissues only. AMien the puncture is due to a gunshot 
wound which injures the shoulder joint or shatters a bone, partial 



BURNS AND SCALDS OP THE SHOULDER AND ARM 



205 



disability of 2 to 6 or 12 weeks may be necessary in preferred 
risks. If the injury has been so severe that permanent deformity 
is the result, partial disability for the full length of the policy may 
be claimed by the injured party. 

EFFECTS : A scar always remains from a punctured wound, 
and if a joint has been entered or a bone fractured, more or less 
permanent deformity and disability ensues. If impaired motion 
follows and is not sufificient to prevent the individual from pro- 
tecting himself in an emergency, any kind of a policy may be is- 
sued three months after recovery. 

BURNS AND SCALDS OF THE SHOULDER AND ARM 

INFORMATION: Burns or scalds of the shoulder and 
arm may result from contact with hot metals, boiling liquids. 




Fig-. 4 3. — Deep burns of the risht shoulder, 
I'creaim, and right buttock. (.Keen's surgery). 

Steam, acids or dry heat. These^ parts are usually protected by 
clothing, consequently the burn is frequentlx' severe, the clothing- 
preventing ready access to the destructive agent for the quick 
removal of the cause. 



vm 



206 INJURIES TO THE SOFT PARTS OF THE UPPER EXTREMITY 

SIGNS AND SYMPTOMS depend on the cause of the bum 
or scald. In all cases, however, there is intense pain, swelling and 
redness surrounding the burn and shock which may be out of all- 
proportion to the size of the burn. Scalds produce bhsters or 
destruction of the tissue when the parts are exposed to heat long 
enough. Hot metals may blister the parts, and if in contact for 
any length of time, carbonization results. 

COMPLICATIONS: Infection or Erysipelas are the usual 
complications following a burn or scald and manifest themselves 
by signs and symptoms peculiar to each affection. 

TOTAL DISABILITY should not be allowed to any class 
of risks when the burn or scald has been superficial and does not 
occupy a large area. Moderately severe and deep burns or scalds 
to these parts usually require from i to 3 weeks of total disability 
in all classes of risks; this time depending on the exact duties of 
the occupation and the area of tissue destroyed. If much slough- 
ing takes place, this disability is prolonged 2 to 4 weeks. Severe 
burns w^hich involve a large area and require skin grafting, cause 
total disability of 6 to 12 wxeks or more in all risks. 

PARTIAL DISABILITY : When a burn or scald involves 
the inner surface of the arm and occurs in preferred risks whose 
duties require much movement of the arm, partial disability of i 
to 3 weeks is sometimes necessary. Ordinary risks are seldom 
partially disabled, for the reason that they do not resume work 
until entirely recovered. 

EFFECTS : Superficial burns or scalds leave no scars, but 
deep ones leave scars which contract and produce deformity and 
sometimes permanent impairment of motion; unless movement 
is greatly interfered with, the individual is insurable for any form 
of policy from three to six months after complete recovery. 

ABRASIONS AND CONTUSIONS OF THE ELBOW 
AND FOREARM 

INFORMATION : Abrasions and contusions of the forearm 
are not infrequent, but in almost every case there are other and 
more severe injuries involving some other part of the body. The 
forearm is one of the selected spots for the production of self-in- 
flicted abrasions and any case suffering from an abrasion of the 
forearm without other injuries should be closely investigated; 
even though an abrasion and contusion exist together, the contu- 



ABRASIONS AND CONTUSIONS OF THE ELBOW AND FOREARM 207 

sion could be as easily produced as the abrasion. Fraudulent 
claimants often select this part of the body for producing these 
injuries, because the parts are accessible for self injury and when 
once inflicted they can be covered up and cause no actual dis- 
ability. 

SIGNS AND SYMPTOMS are the same as such injuries 
would produce in any other part of the body. 

DIFFERENTIAL DIAGNOSIS : Abrasions of the forearm 
that are produced intentionally are usually the result of scratch- 
ing with the finger nails, rubbing sand paper along the forearm 
or confining croton oil against the skin, any of these meaijs pro- 
during an irritation and inflammation. Abrasions when self-in- 
flicted are generally confined to a single area on the flexor surface 
of the forearm, are connected one with the other and the surfaces 
are evenly abraded; while abrasions which are the result of acci- 
dents show the abraded surfaces scattered over the forearm with 
some parts deeply gashed and others superficial, and are almost 
invariably found on the posterior surface. If the abrasion is in- 
tentionally inflicted, a discoloration may exist and is not the result 
of a blow, as it can be produced by the injection of the tincture of 
iodine or permanganate of potash under the skin; but in such 
cases there is always evidence of a small puncture made by the 
needle of the syringe. Discoloration following an accidental in- 
jury is usually more widespread and is not so marked in one 
place as that produced by injection of iodine or permanganate of 
potash. 

COMPLICATIONS : Abrasions that are produced intention- 
ally or occur accidentally are sometimes poisoned as the best 
means of prolonging disability, and this is especially true concern- 
ing this part of the body. Laborers who are suffering from abra- 
sions of the forearm sometimes place a copper cent in vinegar 
until it has become corroded, and then bind this against the abra- 
sion. When an attempt is thus made to prolong disability, evi- 
dence of a violent infection at one point of the abrasion is 
apparent and would serve to excite suspicion that such a means 
had been resorted to for lengthening the period of disability. 

TOTAL DISABILITY following abrasions and sligh't con- 
tusions of the forearm when no other injury exists should not be 
allowed in an}^ class of risks. Ordinary risks are sometimes en- 
titled to 3 to 7 days of total disability following a very severe con- 
tusion of the forearm. 



208 INJURIES TO THE SOFT PARTS OF THE UPPER EXTREMITY 

PARTIAL DISABILITY of i to 2 weeks may be necessary 
in severe contusions of the forearm which occur in individuals 
whose occupation requires much use of the arm and hand. Ordi- 
nary risks are not entitled to this form of disability. 

EFFECTS: Abrasions and contusions recover quickly and 
no permanent impairment remains. 

INCISIONS AND LACERATIONS OF THE ELBOW 
AND FOREARM 

INFORMATION : Incisions involving the forearm are 
frequent and are caused by any sharp instrument. Lacerated 
wounds are usually due to the hand and forearm being caught 
between two hard substances, with the resulting tear of the skin 
and subcutaneous tissue. Self-inflicted incised wounds are some- 
times seen involving the forearm. Such incisions are generally 
long and superficial, being not more than scratches made by a 
sharp instrument and which cause little pain and no disability. 
They run obliquely across the left forearm when the malingerer 
is right handed and vice versa, extending from the external and 
lower part to the upper and internal surface of the forearm. Lac- 
erations when produced b}^ machiner}^ or other violent means are 
generally very extensive and are often accompanied by other 
wounds to diilerent parts of the body. 

SIGNS AND SYMPTOMS : A cleanly cut incision shows 
separation of the wound edges, while those of a lacerated wound 
are torn and ragged. Incised wounds may sever some of the 
blood vessels or nerves of the forearm, in which case there is ex- 
tensive hemorrhage and loss of power beyond the point of injury. 
Pain is always felt and shock may be present in deep incised 
wounds or badly lacerated ones. Infection more commonly fol- 
lows lacerated wounds. 

TOTAL DISABILITY lasts from 5 to 10 days in preferred 
risks following deep incised wounds which do not involve the 
joint. Severe lacerated wounds of the soft tissue only cause total 
disability of i to 3 weeks in all classes of risks. When an incision 
or laceration is severe and involves either the elbow or wrist joint, 
total disability in all classes of risks may last from 3 to 6 or 8 
weeks, depending on the severit}^ of the incision or laceration and 
the resulting infection which follows to the joint. 

PARTIAL DISABILITY of i to 2 weeks is claimed by pre- 



PUNCTURED WOUNDS OF THE ELBOW AND FOREARM 209 

ferred risks following incised or lacerated wounds which do not in- 
volve a joint; if this complication is present, partial disability of 2 
to 4 weeks may be demanded. Ordinary risks are not often en- 
titled to this form of disability; if so, from i to 2 weeks are gene- 
rally sufficient. 

EFFECTS: If the incision or laceration has not been so 
severe as to sever some of the tendons or nerves of the forearm, 
the wound heals with a resulting scar only. Should tendons or 
nerves be divided, loss of power in the hands or fingers may re- 
sult; in which case disability is prolonged. Unless much impair- 
ment of motion remains, the individual is insurable for any kind 
of a policy after recovery is complete. 

PUNCTURED WOUNDS OF THE ELBOW AND 
FOREARM 

INFORMATION : Punctured wounds involving the forearm 
or elbow joint may be the result of sharp-pointed instruments or 
missiles propelled by gun powder. If due to pointed weapons 
that have a sharpened edge, some of the tendons of the forearm 
may be severed as the instrument enters or is extracted from the 
arm. When the punctured wound is due to a gunshot injury, the 
radius or ulna may be shattered or the elbow joint may be badly 
injured. Punctured wounds from pointed instruments, unless en- 
tering a joint, seldom cause any permanent disability, while the 
same class of wounds by bullets usually cause permanent de- 
formity and disability when the missile comes in contact with 
one of the bones or enters the elbow joint. 

SIGNS AND SYMPTOMS following small punctured 
wounds from knife blades, nails, splinters, etc., which involve the 
soft tissues of the forearm only are pain, slight bleeding, swelling 
and generally suppuration. If the instrument has a sharp edge 
and some of the tendons have been severed, absence of flexion or 
extension of the hand or fingers may be evident. Following a 
puncture due to gunshot injury, there is shock which may be se- 
vere and this is especially true if the bullet wounds any of the ar- 
teries, nerves or bones of the forearm. Bleeding, with pain, ten- 
derness, swelling and evidence of the puncture is seen. If either 
of the bones is fractured, a false joint with crepitation results, 
and if the bones entering into the formation of the elbow joint 
are injured, there is loss of motion in this articulation with crepi- 
14 



mi 



210 INJURIES TO THE SOFT TISSUES OF THE UPPER EXTREMITY 

tation between the fractured ends of the bones and in some cases 
synovial fluid can be detected as coming from the joint. 

COMPLICATIONS: Infection usuahy follows a punctured 
wound unless it is very shallow and can be easily cleaned immedi- 
ately following its infliction. If the instrument or missile enters 
the elbow joint, infection is almost sure to ensue and prolong dis- 
ability in addition to causing more or less permanent impairment 
of motion in this articulation. 

Fractured Bones as the result of gunshot injuries are usual in 
this part of the body, and if the upper extremity of the radius or 
ulna or the lower end of the humerus is injured, infection almost 
invariably follows, and when recovery ensues, impairment of mo- 
tion of this joint results. 

TOTAL DISABILITY in preferred risks when the punc- 
ture has been made by a pointed instrument and no tendons have 
been severed, lasts from 2 to 7 days. Ordinary risks seldom de- 
mand any total disability for small punctured wounds. If the in- 
strument making the puncture has cut any of the tendons of the 
forearm and is followed by infection, total disability in preferred 
risks lasts from 2 to 4 weeks, when the injury has occurred to 
the right forearm. In the same class, if the injury is to the left 
forearm and the individual is right handed, total disability lasts 
from I to 2 weeks, unless the occupation requires constant use 
of both arms, when total disability is, as above stated, for pre- 
ferred risks. Ordinary risks require from 3 to 5 weeks of total 
disability following these injuries. Punctured wounds of the 
forearm from gunshot missiles that do not injure the bones, ten- 
dons or joints require the same length of time in all classes of 
risks as simple punctured wounds which become infected. Gun- 
shot wounds which fracture one or both bones of the forearm or 
sever some of the tendons cause total disability of 3 to 6 or 8 
weeks in preferred risks when the injury occurs to the right fore- 
arm and the individual is right handed. If the duties of the occu- 
pation are clerical and the injury occurs to the left forearm, total 
disability usually lasts from i to 3 weeks only in preferred risks. 
In ordinar}^ risks, total disability lasts from 3 to 6 weeks in this 
class of injuries to either one of the forearms. Preferred risks 
who require the use of both arms in the occupation and who suffer 
from a gunshot wound of the right elbow, require from 6 to 10 
weeks of total disability. If the duties are office and supervising, 
from 3 to 6 weeks of total disability are generally suf^cient, when 



BURNS AND SCALDS OF THE ELBOW AND FOREARM 211 

the injury occurs to the left elbow and the claimant is right- 
handed. Ordinary risks suffering from a gunshot injury to the 
elbow joint require from 6 to 12 weeks of total disability and 
sometimes a longer period is necessary. 

PARTIAL DISABILITY of i to 2 weeks in preferred risks 
suffering from a simple punctured wound of the forearm is some- 
times demanded. If the instrument which penetrates the forearm 
severs some of the tendons, partial disability of 2 to 4 weeks is 
often payable to preferred risks. Gunshot wounds which fracture 
either of the bones of the forearm in preferred risks require from 
2 to 4 weeks of partial disability. If the fractured bones enter 
into the formation of the elbow joint, from 4 to 8 weeks or more 
may be necessary. Preferred risks suffering from gunshot 
wound's of the forearm in which total disability has been short, 
usually require from 2 to 4 weeks of partial disability. Ordinary 
risks are not often entitled to any partial disability following punc- 
tured wounds of any character to the forearm. 

EFFECTS : Ordinary punctured wounds that are uncompli- 
cated except by infection, and which do not involve a joint, leave 
no permanent deformity. If the puncture has severed some of 
the tendons of the forearm and these have not been properly 
sutured together, some impairment of flexion or extension of the 
hand or fingers may be present, but motion usually returns in time. 
Should the puncture have been due to a gunshot injury and frac- 
tured the radius or ulna, there may be permanent deformity and 
some temporary weakness immediately following the injury. This 
disappears, however, and the arm becomes as strong as ever, even 
though slightly deformed. If the elbow joint is involved, deform- 
ity and more or less impairment of motion almost invariably re- 
sults. If this is not so great as to prevent the individual from 
gaining his livehhood or taking care of himself in an emergency, 
any form of insurance may be written from three to six months 
after complete recovery. 

BURNS AND SCALDS OF THE ELBOAV AND FOREAR^f 

INFORMATION: Burns and scalds of the elbow and fore- 
arm are frequent to risks who w^ork with the . sleeves rolled up 
and are caused by the accidental application of heat in various 
forms to this part of the body. This class of injuries when super- 
ficial cause little, if any disability, but when severe, disability is 



212 INJURIES TO THE SOFT PARTS OF THE UPPER EXTREMITY 

greatly prolonged and deformity with permanent impairment of 
motion usually results. 

SIGNS AND SYMPTOMS: Immediately following a burn 
or scald there is pain, tenderness, swelling, redness, and if the 
heat is intense, blisters or destruction of the tissues results. Sup- 
puration is usual in this class of burns and prolongs disability. 

DIFFERENTIAL DIAGNOSIS: Pemphigus is a disease 
commonly found on the limbs and is characterized by blisters 




Fig. 44. — Pemphigus in a negress aged thirty-one, of two montlis' duration, showing 
the fresh, tense, and older flaccid blebs on upper arm; eruption general. (Stelwagon"». 

which form in crops with no area of inflammation surrounding 
them. These blebs varying in number from six to twelve, from 
small spots to several inches in diameter, and are accompanied 
by slight itching and burning. When this disease has existed for 
some time, it resembles a superficial scald. 

TOTAL DISABILITY following slight burns or scalds of 
the elbow or forearm cause little if any disability in preferred 
risks. Aloderately severe burns in this location require from i to 

2 weeks in this class of risks, if the injur}^ is to the right forearm 
and the individual is right-handed. When the burn occurs to the 
left forearm under the same conditions, total disability lasts from 

3 to 7 da3'S only. Severe burns in which a large surface of skin 
and some of the underlying tissue have been destroyed, require 
from 3 to 6 weeks of this disability in preferred risks when the 



ABRASIONS AND CONTUSIONS OF WRIST, HAND AND FINGERS 213 

injury occurs to the right forearm. If to the left forearm under 
these conditions, total disability lasts from i to 3 weeks. Ordinary 
risks seldom require any total disability for slight burns. Moder- 
ately severe burns require from 3 to 7 days and severe ones from 
2 to 3 weeks. If skin grafting is necessary in this class of risks, 
the primary period of total disability is generally long and is in- 
creased 2 to 3 weeks for each skin grafting operation. 

PARTIAL DISABILITY lasts from i to 4 weeks in pre- 
ferred risks, according to the location of the burn, its severity, 
compHcation and the exact duties of the occupation. Some in- 
dividuals insured under an ordinary classification require from i 
to 2 weeks of partial disability. 

EFFECTS : Severe burns or scalds of the elbow or forearm 
that are deep enough to involve the tendons or nerves of the ex- 
tremity cause permanent deformity and disability. The tendons 
of the forearm may be bound together by adhesions and thus 
cause limited motion in the hand or fingers. If a considerable 
area of skin wdth the underlying tissue on the flexor surface of 
the elbow is destroyed, an ugly scar which contracts in time re- 
sults and may produce permanent partial flexion of this joint. As 
the scar grows older, it becomes harder and is continually split 
open by unintentional efforts on the part of the individual to ex- 
tend the arm, causing a more or less open abrasion on the an- 
terior surface of this joint at all times. Individuals who have suf- 
fered from severe injuries to this part of the extremity which have 
recovered without much permanent deformity or disability, are 
insurable for any kind of a pohcy from three to six months after 
recovery. 

ABRASIONS AND CONTUSIONS OF THE WRIST, 
HAND AND FINGERS 

INFORMATION : Abrasions of the wrists, hands or fingers 
cause total or partial disability when the injury is confined to this 
part of the body, and in certain occupations, such as bookkeepers, 
telegraph operators, stenographers, clerks, etc.; while contusions 
to these parts, unless extremely severe, seldom cause total disabil- 
ity in any class of risks. Injuries that are more than contusions, 
such as a mashed finger or hand in which the skin is not broken, 
cause total and partial disability in all classes of risks. Abrasions 
of the hands and fino-ers are usually the result oi falls and are 



214 INJURIES TO SOFT PARTS OF UPPER EXTREMITY 

caused by sliding of the hands along the ground or on some hard 
substance. Severe contusions are produced by the fingers or 
hand being caught between two hard objects and badly squeezed 
and mashed. Some contusions are not received accidentally, such 
as the swollen discolored hands of a base-ball catcher, who is not 
insurable for an accident policy. 

SIGNS AND SYMPTOMS: Abrasions present the charac- 
teristic evidence of broken skin with bleeding, swelling, and later 
the formation of scabs. Infection of these superficial wounds fre- 
quently follows abrasions of the hands or fingers. Contusions re- 
sult in swelling, discoloration, stiffening of the joints of the wrists, 
hands or fingers, and if the contusion has been severe and involved 
the ends of the fingers or thumb, discoloration appears under the 
nail and persists for a great length of time, in addition the nail is 
often discarded as a result of these injuries. Pain and tenderness 
follow abrasions and contusions and are especially severe on miove- 
ment when the injur}^ involves the fingers. 

COMPLICATIONS: Infection is one of the most frequent 
results of an abrasion to the hand or fingers, but generally it does 
not prolong disability unless the abrasion is very extensive and in- 
volves a large area. 

A Palmer Abscess sometimes follows a severe contusion of the 
hand, but this is most often due to prolonged and frequent use of 
the palm against a pick handle or some other instrument in which 
a constant gripping and pressing of the hand against a hard object 
is necessarv. If an abscess in this localitv results there is oTcat 
swelling of the hand, which is more pronounced on the palm, and 
accompanied by intense pain and high fever. An operation is al- 
ways imperative in these cases and disability is thus greatly pro- 
longed. 

TOTAL DISABILITY following extensive abrasions of the 
hand or fingers lasts from 3 to 7 days in individuals whose occupa- 
tion requires the constant use of the fingers or hand, such as tele- 
graph operators, clerks, etc. Contusions of the hand or fingers 
seldom produce total disability, unless the injury is more than a 
contusion and causes a severe mashing without breaking the skin, 
when total disability in preferred risks who require constant use 
of the hands in the occupation, lasts from 5 to 10 days. Ordinary 
risks are seldom entitled to total disability for any abrasion or 
contusion of this part of the bodv. unless it can be clearlv shown 



INJURIES OF THE WRIST, HAND AND FINGERS 



215 



that a palmer abscess resulted from an accidental contusion; in 
which case total disability lasts from 2 to 4 weeks. 

PARTIAL DISABILITY in preferred risks when the injury 
occurs to the right hand and the individual is right-handed, lasts 
from 3 to 7 days as the result of an abrasion, and from i to 3 
weeks when a severe contusion has occurred. Infection some- 
times prolongs this period of partial disability, though rarely. Or- 
dinary risks are not entitled to any partial disability following this 
class of injuries to this part of the body. 

EFFECTS : Abrasions heal without any noticeable scar, and 
unless the contusion has been so severe as to cause the loss of a 
nail, no permanent marks remain and the individual is insurable 
for any kind of a policy as soon as recovery is complete. 

INCISIONS AND LACERATIONS OF THE WRISTS, 
HANDS OR FINGERS 

' INFORMATION: Incised wounds of the wrists, hands or 
fingers are very frequent and superficial, and seldom cause any 
disability unless the cut has severed 
some of the tendons, when total 
and partial disability ensue. Lacer- 
ations to this part of the body oc- 
cur more often in ordinary risks 
than in those of the preferred class. 
Lacerated wounds as the result of 
injuries by machinery and crushing 
between hard substances are usually 
very much contused and on account 
of foreign bodies being ground into 
these surfaces, infection almost in- 
variably follows and disability is 
greatly prolonged by this and also 
by the severe mashing of the parts 
which occur in these injuries. Muti- 
lation of the hands or fingers by 
chopping off the end of a finger or 
thumb is sometimes practiced bv 
individuals who carry a number of 
accident policies. This is especially 
true when the policy pavs a specified 
■sum for the loss of a fino-er or hand. (Eisendiatu^. 




severe lacerations* of 



following 
the hand. 



216 INJURIES TO SOFT PARTS OF THE UPPER EXTREMITY 

In these self-inflicted cases, the individual generally selects the 
left hand for mutilation and at a time when no one is present. 

SIGNS AND SYMPTOMS are pain and hemorrhage with 
cleanly cut surfaces in incised and torn and ragged ones in lacer- 
ated wounds. If any of the tendons have been severed, loss of 
function follows in the muscle involved. When a nerve has been 
divided, paralysis or loss of sensation exists beyond the point of 
injury. 

DIFFERENTIAL DIAGNOSIS: Incised or lacerated 
wounds involving the wrists, hands or fingers are easily diagnosed, 
but the question as to whether the injury is received accidentally 
or self-inflicted is sometimes extremely difficult. Accidents that 
resLilt in these injuries occur to individuals during the course of 
the day's labor and are usually witnessed by co-employees or 
friends. When the injury is self-inflicted it is more often claimed 
that it occurred on the train or trolley, in order that double in- 
demnity may be payable. If this is not attempted, the malingerer 
states that the injury occurred at night or when no one was pres- 
ent, and almost invariably the left hand is the one selected, unless 
the individual is naturally left-handed. Examination of the other 
hand or the toes of both feet in these cases usually shows some 
loss of the parts which have most probably been self-inflicted 
previously. Such persons deny having any other accident insur- 
ance, but investigation always discloses the fact that the individual 
is insured by a number of companies. 

COMPLICATIONS: Infection or Tetanus may supervene 
and compHcate any incised or lacerated wound, and infection is al- 
most invariably present following a lacerated wound of the hand 
or fingers. 

TOTAL DISABILITY: Incised or lacerated wounds of the 
wrists, hands or fingers which do not sever any of the tendons 
and occur in preferred risks who are right handed and whose 
duties require constant use of the hands may last from 3 to lo 
days; under the same conditions when the injury is to the left 
hand, total disabihty is rarely deserved. If a tendon has been sev- 
ered or a joint opened and infected, total disability in preferred 
risks such as stenographers, telegraph operators, etc., lasts from 
3 to 6 weeks. If the duties are office only and the injury occurs 
to the left hand, total disability lasts from 3 to 7 days. Ordinary 
risks are totally disabled by deep incised or lacerated wounds 



INJURIES OF THE WRIST, HAND AND FINGERS 217 

from I to 3 weeks, according to the duties of the occupation and 
the location of the injury. 

PARTIAL DISABILITY of i to 2 or 3 weeks follows in 
preferred risks who suffer from an incised or lacerated wound 
involving these parts; ordinary risks are seldom entitled to any 
partial disability. 

EFFECTS: These injuries heal and leave a scar which is 
more or less prominent according to the severity of the injury. 
If a tendon has not been severed or an infection of the joint oc- 
curred, there is no resulting deformity or disability, and even if a 
condition such as a stiff joint or loss of flexion or extension in 
one of the fingers or thumb follows, the individual is insurable for 
any kind of a policy as soon as recovery is complete. On account 
of the frequent use of the hand and fingers, stiffening or loss of 
motion in the fingers or thumb generally improves in time. 

PUNCTURED WOUNDS OF THE WRISTS, HANDS 
OR FINGERS 

INFORMATION : Punctured wounds involving the fingers, 
hands or wrists are frequent and are due to splinters, sharp- 
pointed instruments and missiles from fire-arms. Bites from ani- 
mals or insects are punctured wounds, and disability resulting 
from such is covered by an accident policy; but in these cases the 
claimant must know when the puncture was made, and this is 
especially true if it is claimed as the result of an insect bite. An 
individual who awakes in the morning with a small swelling on 
the hand or fingers and thinks it is due to an insect bite received 
during the night, is not entitled to indemnity under an accident 
policy, for the reason that he does not know positively the cause 
of the swelling; he merely thinks that it was due to an injury, but 
cannot be sure of it. Punctured wounds unless due to bullets, sel- 
dom injure any of the bones, but may enter the joints and cause 
an infection. Small punctured wounds to the soft tissues only 
rarely cause disability in any class of risks; when the puncture is 
deep and involves a joint, and this is followed by infection, total 
and partial disability ensue, but this depends on the location of the 
wound and the occupation of the individual. Gunshot injuries 
to the wrists, hands or fingers are very destructive and are usually 
complicated by a fracture of some of the bones, infection of a 
joint or the severance of tendons. Fraudulent claimants some- 



218 



INJURIES TO SOFT PARTS OF THE UPPER EXTREMITY 



times mutilate themselves by shooting off the end of a finger or 
a thumb for the purpose of receiving indemnity under a number 
of insurance policies. 




Fig. 4 6. — X-ray of gunshot wound of hand showins 
bedded on metacarpal bone of thumb. (Eisendrath). 



bullet em- 



SIGNS AXD SYMPTOMS are an opening in the skin. 
which is plainly evident and which may contain a part of the sub- 
stance causing the puncture. Pain, swelling and bleeding follow, 
and if the puncture is due to a gunshot injury and involves a 
joint, loss of motion results; some shock follows punctured 
wounds when caused by firearms, and if the instrument is held 
close enough to the skin, powder burns with particles of powder 
are imbedded in the tissues. 

DIFFERENTIAL DIAGXOSIS: Punctured IVounds involv- 
ing the hand or fingers when self-inflicted by fire-arms injure the 
extremitv which is least used and at a time when witnesses are not 



INJURIES OF THE WRIST, HAND AND FINGERS 219 

present and under peculiar circumstances that are hard to ex- 
plain if the claimant is property and closely questioned. These 
individuals seldom tell the same story as to the exact cause of the 
injury, and in addition have a history of being of little use to the 
community in which they reside. 

COMPLICATIONS: Infection almost invariably follows a 
punctured wound to this part of the body and prolongs disability 
according to the location of the injury and the degree of infection. 

Tetanus may complicate any punctured wound, and this is 
especially true when the puncture has occurred in the street or 
in a barnyard and is made by a nail or other sharp instrument in 
use in such a place. This disease frequently follows a punctured 
wound as the result of the discharge of a blank cartridge when 
held in close proximity to the injured part. 

TOTAL DISABILITY depends on the occupation of the in- 
dividual, the location of the injury, the cause and the complica- 
tion. Simple punctured wounds when made by sharp pointed in- 
struments in the soft tissues of wrist, hand, thumb or fingers sel- 
dom cause total disability, unless the individual is a musician, ma- 
chine typesetter, telegraph operator, etc., when from 3 to 7 days 
may be necessary. If the puncture ^enters one of the numerous 
joints and is followed by infection, total disability in preferred risks 
lasts from i to 3 weeks, according to the location of the puncture 
and the exact duties of the individual. Gunshot wounds involving 
the wrist, hand, thumb or fingers in preferred risks requiring the 
constant use of the right arm and hand, cause total disability of 4 
10 6 weeks. Preferred risks whose duties are office and supervis- 
ing require from i to 2 weeks of total disability for these injuries. 
Ordinary risks rarely demand this form of disability for 
simple punctured wounds. When the injury involves a joint, 
total disability lasts from 2 to 4 weeks. If the puncture is due 
to a gunshot injury, from 4 to 6 or 8 weeks are necessary before 
the occupation can be resumed. Preferred and ordinary risks suf- 
fering from animal, insect or human bites are usually disabled the 
same length of time as from a punctured wound that is badly in- 
fected. 

PARTIAL DISABILITY following simple punctured 
wounds sustained by preferred risks sometimes requires from 5 
to 10 days. If the puncture has involved a joint and occurred to 
the left hand of a preferred risk, partial disability of i to 3 weeks 
mav be necessary. Gunshot injuries in this class of risks require 



220 INJURIES TO SOFT PARTS OF THE UPPER EXTREMITY 



I 



from 2 to 4 or 6 weeks when the puncture occurs to the left hand 
and not as long when to the right. Partial disability of i to 3 
weeks is generally payable to preferred risks suffering from ani- 
mal, insect or human bites. Ordinary risks seldom ask for partial 
disability following any character of punctured wounds. 

EFFECTS : Simple punctured wounds heal readily and leave 
a small scar. Badly infected wounds and those w'hich may in- 
volve a joint, sometimes leave impaired motion in the affected 
articulation. Gunshot wounds always leave unsightly, depressed 
scars and a certain amount of impairm.ent of motion and deform- 
ity. ^Motion in the hand or fingers usually becomes practically 
normal in time even after a severe punctured wound; the indi- 
vidual therefore is insurable for any kind of insurance as soon as 
recovery is complete. 

BURXS AXD SCALDS OF THE WRISTS, HANDS 
OR FIXGERS 

IX^FORMATION: The fingers, hands and wrists together 
with the face and neck being the most exposed parts of the body 
most frequently suffer from burns or scalds Avhich may be of any 
degree of severity, from the most slight and superficial to very 
severe ones that are very destructive and leaA^e permanent de- 
formity and disability. They are caused by wet or dry heat com- 
ing in violent contact with these parts and total and partial dis- 
abilit}' often results from what is apparently only a trivial burn 
or scald. 

SIGX^S AX^D SY]\IPT03kIS are swelling with redness, pain 
and frequently blisters, and when the burn is produced by pro- 
longed contact with hot metals, the parts are carbonized; infec- 
tion almost invariably follows these burns or scalds and in many 
cases sloughing also occurs. Loss of motion is present when the 
burn has been severe and sometimes the tendons are exposed. 

TOTAL DISABILITY: Preferred risks whose duties re- 
quire constant use of the hands or fingers require from i to 2 
weeks in slight burns or scalds; from 2 to 3 weeks in moderately 
severe ones, and from 3 to 6 weeks when the burn has been ex- 
ceedingly severe. If the duties are oflice and supervising in the 
same class and the injury occurs to the left hand, from i to 5 days 
are generally suf^cient in burns or scalds of all degrees of sever- 
ity. Ordinary risks are totally disabled from 5 to 10 days fol- 



PALMER ABSCESS 



221 



lowing- slight burns of the hands which involve a considerable 
area. If a burn or scald is moderately severe, from 2 to 3 weeks 
are required, and when the injury is very severe, total disability 
may be greatly prolonged; from 4 to 6 weeks, however, is the 
usual time. If an operation for skin grafting is necessary in any 
of these cases, it prolongs total disability from 2 to 3 weeks for 
each time that it is performed. 

PARTIAL DISABILITY of i to 2 weeks is payable to pre- 
ferred risks when the duties require constant use of the hands 
or fingers, and from i to 3 weeks in the same class when the occu- 
pation is office and supervising. Partial disability of i to 2 weeks 
is sometimes payable to ordinary risks. 

EFFECTS : Slight burns or scalds involving the wrists, 
hands, fingers or thumbs may leave scars that are more or less 
noticeable. Severe burns or scalds are always followed by scars 
which contract and usually produce impairment of motion. If 
the burn has been extremely severe and the deep tissues have been 
destroyed, scars and deformity are marked and impaired move- 
ment is permanent. Unless this impairment is so pronounced that 
the individual is unable to protect himself in an emergency, insur- 
ance of all kinds can be written as soon as recovery is complete. 

PALMER ABSCESS 



INFORMATION: An abscess in- 
volving the hand is frequently due to 
traumatism to the palm, although an 
injury to either of the fingers and es- 
pecially the little finger and the thumb 
may be followed by suppurative the- 
citis and a palmer abscess. A palmer 
abscess is generally seen in laboring' 
men and most commonly results from 
repeated contusions to the palm of the 
hand, such as would occur when a 
workman is constantly striking or ptish- 
ing his palm against a hard substance. 
Base ball players are subject to these 
abscesses which are produced by the 
ball continually pounding the anterior 
surface of the hand. L'^nless an abscess 
of this kind is promptly and properly 




-Piagiaiu of tendon- 
tho hand. rVillaux"*. 



222 INJURIES TO SOFT PARTS OF THE UPPER EXTREMITY 

treated by free incisions, disability is greatly prolonged and per- 
manent deformity and loss of motion may result. 

SIGNS AND SYMPTOMS are swelling of the palm which 
becomes greatly puffed out, followed by redness and excruciating 
pain Avhich is worse when the hand is in the dependent position;, 
high fever, loss of appetite and inability to sleep are always pres- 
ent. 

COMPLICATIONS: If the abscess is not opened promptly 
by deep incisions, pus burrows under the palmer fascia and ex- 
tends up the forearm. Sloughing of the flexor tendons and some- 
times the extensors occurs; necrosis of the carpal bones of the 
hand results when the abscess is only confined a comparatively 
short time. 

TOTAL DISABILITY : As this condition almost invariably 
occurs in the laboring classes or those who are insured as ordi- 
nary or more hazardous risks, total disability lasts from 3 to 6 
weeks when the abscess has been freely opened in the early stages. 
If not so treated, these risks may be totally disabled for an uncer- 
tain length of time running from 4 to 6 or 8 weeks and often 
longer, depending on the amount of destruction of the tissues of 
the hands before the abscess is evacuated. 

PARTIAL DISABILITY is not often deserved in this class 
of risks as the claimant is fully recovered before being able to 
resume any part of his occupation. 

EFFECTS : A palmer abscess that has been opened early 
and has healed without any complications, causes no permanent 
deformity to the hand. If sloughing of the tendons occurs or ne- 
crosis of the carpal bones ensues, the individual is an impaired 
risk for accident insurance; the degree of impairment depending 
on the deformity and loss of function which is present in the hand. 
Such individuals are insurable for life or health policies as soon as 
recovery is complete, but the issuance of an accident policy would 
require that each case be considered separately. 



SPRAINS OF THE SHOULDER JOINTS 22^ 



PART II 

INJURIES TO THE ARTICULATIONS OF THE UPPER 
EXTREMITIES 

SPRAINS OF THE ACROMIO-CLAVICULAR AND 
SHOULDER JOINTS 

INFORMATION: Sprains of the acromio-clavicular joint 
are rare and when they do occur are usuaUy seen as compHcations 
involving a contusion, sprain or dislocation of the shoulder joint. 
This important ball-and-socket joint is not often sprained on ac- 
count of its great range of motion, but sometimes a sprain re- 
sults when the arm is caught and twisted by falls from a height 
On the extended arm and by direct force which causes the head 
of the humerus to be temporarily and partially displaced. 

SIGNS AND SYMPTOMS: Immediately following a 
sprain of the shoulder joint there is intense pain accompanied by 
a feeling of weakness, sometimes nausea and vomiting, and when 
the injury has been severe, syncope may occur; swelling appears 
quickly and discoloration of the superficial tissues may result in 
a short time, although in the shoulder joint, discoloration is not 
marked until several days after the injury has been received. 
After a severe sprain, pain is increased by motion, tenderness is 
present over certain places and in a short time grating on move- 
ment is elicited. 

DIFFERENTIAL DIAGNOSIS: Acute Articular Rheuma- 
tism may commence in the shoulder joint, and if the 
individual has had a slight fall, he may imagine that the 
joint has been injured. This disease produces uniform 
swelling, redness, no discoloration of skin over the joint, but a 
marked sense of heat, increased body temperature, excruciating 
pain on the slightest movement and tenderness which is present 
over the entire surface of the shoulder joint; as the disease ad- 
vances other joints become affected, acid sweats occur and in 
marked cases anemia results. Sprains have a history of a severe 
injury followed by tenderness which appears in spots marking the 
tear of the li£>'aments or tissues surrounding' the joint ; swolliui:;- and 



224 INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 

discoloration occur. The latter follows a sprain, while it is absent 
in a joint affected with rheumatism. Sprains produce no general 
increase of temperature and the tenderness surrounding the joint 
gradually becomes less as time passes and is not changed by 
weather conditions, 

COMPLICATIONS : Fractures and Dislocations are some- 
times present in an injury diagnosed as a sprain, but in the 
shoulder and acromio-clavicular articulations such an error seldom 
occurs. 

Acute Synovitis invariably results when a sprain of the 
shoulder joint has been sustained and blood has been extravasated, 
but proper treatment prevents this inflammation becoming 
chronic. Should it become so, however, impairment of motion 
results and disability is prolonged. 

TOTAL DISABILITY lasts from 3 to 7 days in preferred 
risks when a moderately severe sprain of the shoulder or acromio- 
clavicular articulations occurs. In the same class suffering from 
a severe sprain of either of these joints, accompanied by marked 
contusions of the surrounding tissues, total disability may last 
from I to 2 weeks. This is especially true in claimants whose oc- 
cupation requires the constant use of the arms. Ordinary risks 
require from i to 3 weeks of this disability for sprains of these 
joints, the time depending on the severity of the injury and the 
duties of the occupation. 

PARTIAL DISABILITY of i to 2 weeks is payable to pre- 
ferred risks when the sprain has been moderately severe and the 
length of total disability has been short. In the same class of 
risks after a severe sprain has been sustained, when total disability 
has lasted from i to 2 weeks, it may be necessary to allow from 
2 to 3 weeks of partial disability. Ordinary risks are not entitled 
to partial disability following this injury. 

EFFECTS : Individuals who have suffered from a sprain of 
either of these joints are generally completely recovered in from 
two to three months from the date of accident, when insurance 
of all kinds can be safely written. 

DISLOCATION OF THE ACROMIO-CLAVICULAR 
ARTICULATION 

INFORMATION : The outer end of the clavicle articulates 
with a facet on the anterior surface of the acromion process of 



DISLOCATION OF THE ACROMIO-CLAVICULAR JOINT 225 

the scapula and is held in place by a strong capsular ligament. 
When a dislocation involving this articulation occurs, the outer 
end of the clavicle is pushed above or below the acromion pro- 
cess, thus tearing and lacerating the upper or lower portion of the 




FIG. 48. — DISLOCATION UPWARD OF THE ACROMIAL END OF 

THE CLAVICLE. (Eisendrath). 

The arrow points to the depression lying between tlie bony prom- 
inence, caused by the separation of tlie acromial end of tlie clavicle 
from the acromion process of the scapula. 



capsular ligament. This dislocation is rare and when seen is 
caused by violent direct force applied to the shoulder joint. After 
this ligament is once torn and lacerated, these dislocations are 
prone to recur on the slightest exertion or injury, unless the bones 
are wired in position. 

SIGNS AND SYMPTOMS: A swelling over this joint is 
present and on palpation it is learned to be the outer end of the 
clavicle resting on the acromion process of the scapula; motion 
in the affected arm is impaired, it being impossible to raise the 
hand above the head. Apparent lengthening of the arm exists, 
the head is drawn towards the injured side, there is some pain, 
and shortly after the injury occurs, discoloration appears. 

COMPLICATIONS: Fractures of the Acromion Process of 
the scapula and fractures of the clavicle sometimes complicate 
these dislocations; when present the usual signs and symptoms 
characteristic of the peculiar complication which exists are 
elicited; such complications prolong the disability. 

TOTAL DISABILITY lasts from 2 to 4 weeks in preferred 
risks whose occupation requires the constant use of the arms and 
hands. In the same class when the duties are mainly directing, 
from 2 to 5 days are generally sufficient. Ordinary risks are 
totally disabled from 3 to 6 weeks following this injury. 



226 INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 

PARTIAL DISABILITY of i to 3 weeks is usually de- 
manded by preferred risks whose duties require much use of the 
arms; in the same class when the period of total disability has been 
short, partial disability of 2 to 4 weeks is generally necessary. Or- 
dinary risks are not often entitled to partial disability. 

EFFECTS: Dislocations of this joint are easily reduced, but 
the result is seldom satisfactory, the slightest injury or muscular 
action causing the dislocation to recur; unless the ends of the 
bone are held in position by wiring. If an operation has not been 
performed, such individuals are not insurable for an accident policy 
without a waiver eliminating indemnity for this disability. They 
would be insurable, however, for a life or health policy from one 
to two months after the date of injury. 

DISLOCATION OF THE SHOULDER JOINT 

INFORMATION: The anatomical position of the shoulder 
joint together with the form of the bones which enter into its for- 
mation, is such that luxations often take place. Dislocations in- 
volving this articulation are said to occur more frequently than 
dislocations involving all the other joints of the body combined. 
They are caused by direct force such as blows to the shoulder and 
by indirect force when a fall has been sustained on the extended 
hand and are more common in young muscular adults. Disloca- 
tions of the shoulder are divided into- four classes, the sub-cora- 
coid, sub-glenoid, sub-spinous and sub-clavicular ; the first of which 
occurs in about three-fourths of the cases. 

SIGNS AND SYMPTOMS: Immediately following a dislo- 
cation there is pain of a nauseating character, free perspiration and 
weakness which is often accompanied by fainting. On inspection 
an apparent projection is seen at the upper part of the joint which 
is the acromion process of the scapula, flattening of the shoulder, 
with a depression immediately under this projection, loss of move- 
ment in the affected arm and extensive swelling. On examination 
the head of the humerus is out of normal position and is found ab- 
normally placed; the position determining the character of luxa- 
tion. If the hand on the injured side is placed on the sound shoul- 
der, the elbow will not touch the side of the chest. Discoloration 
which is very extensive and involves the whole shoulder and ex- 
tends down the arm follows a dislocation of the head of this bone. 

DIFFERENTIAL DIAGNOSIS: Fractures involving the 
surgical or anatomical neck of the humerus, the glenoid fossa or 



DISLOCATION OF THE SHOULDER JOINT 



227 



neck of the glenoid process, the coracoid or the acromion pro- 
cesses, may be present in addition to a dislocation. When frac- 
tures of the surgical or anatomical neck of the humerus occur, 
there is crepitation on movement which is not present in a dislo- 
cation and the movement is more free than in a dislocation. If a 
fracture exists in this situation, it is easily reduced, but at once 
recurs. Dislocations are difficult of reduction, and when once 
returned to place remain in position. When fractures of the cora- 




Pig-. 49. — Subcoracoid dislocation of the hum- 
erus showing flattening of the shoulder, the 
position of the arm and forearm, and the posi- 
tion of the head of the humerus in relation to 
the other bony landmarks. (Hoffa). 

coid or acromion processes occur, this part of the scapula is found 
resting on the head of the humerus and crepitation is present be- 
tween the process and the scapula. 

Paralysis of the Deltoid Muscle produces distinct flattening of 
the shoulder, but the head of the humerus is found in position and 
motion is somewhat impaired in the joint. 

The X-rays should always be used in injuries of the shoulder 
joint, for the purpose of ascertaining the extent of the injury. 



228 INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 

Many cases of dislocations are complicated by fractures of some 
parts of these bones which are very difficult of diagnosis without 
the rays. By using this method, a physician has a better concep- 
tion of the injury and is thus able to give his patient the best 
treatment and also forestall any claim for damages for improper 
treatment, or be better prepared to defend himself in such a case. 

COMPLICATIONS: Injuries to Blood Vessels and Nerves. 
As the head of the humerus breaks through the capsular Hgament 
of the shoulder joint when a dislocation occurs and takes up its 
new position, laceration and tearing of the arteries, veins and 
nerves of the axilla follow. If the brachial artery is torn, absence 
of the radial pulse on the injured side is apparent and rapid ex- 
travasation of blood into the axilla follows, this extending down 
the inside of the arm and under the skin of the chest, producing 
signs of concealed hemorrhage, such as nausea and faintness, 
rapid, irregular pulse, etc. This collection of blood may become 
infected and result in an axillary abscess, when disability is pro- 
longed, the time depending on the extent of the abscess and the 
physical condition of the individual. If some of the nerves have 
been injured, sensation in the parts supplied by the injured nerve 
is impaired or lost or motion is impossible. 

Com pound Dislocations or dislocations in which the soft tissues 
are so torn that an opening is established between the joint and 
the external surface are extremel}^ rare. They may occur, how- 
ever, when the violence has been so great that laceration of the 
soft tissues surrounding the shoulder joint is present, and when 
seen, disability is greatly prolonged and may even result in an am- 
putation at the joint on account of the laceration accompanying 
the dislocation. 

TOTAL DISABILITY lasts from 2 to 3 weeks in preferred 
risks who require the constant use of the arms; in the same class 
when the duties are office and supervising, this disability persists 
from 3 to 7 days only and is followed by a longer period of partial 
disability. Ordinary risks are totally disabled from 3 to 5 weeks 
following these dislocations. The above time of disabiHty is for 
uncomplicated dislocations; should any complication occur, the 
length of disability depends on the character and severity of the 
complication. 

PARTIAL DISABILITY in preferred risks, such as tele- 
graph operators, stenographers, etc., requires from i to 2 weeks; 
in the same class when the period of total disability has been short 



SPRAINS OF THE ELBOW JOINT 



229 



and the occupation is mostly directing, partial disability of 2 to 4 
weeks is necessary. Ordinary risks are not usually entitled to 
any partial disability. 

EFFECTS: Dislocations of the shoulder j"oint are prone 
to recur, and it is impossible to tell when the same condition may 
be again produced; therefore, an individual with a history of such 
an injury within one to two years would not be insurable for an ac- 
cident policy unless a waiver was placed on it eliminating disabil- 
ity for this injury. Life and health insurance can be safely writ- 
ten on such a case at any time after recovery takes place. 

SPRAINS OF TFIE ELBOW' JOINT 



INFORMATION: The elbow joint is a pure hinge-joint 
and receives its strength more from the shape of the bones than 
the ligaments which surround it and hold them in contact with 
each other. It consists of three separate, distinct articulations 
and is subject to sprains caused by falls on the extended hand, 
severe blows over the joint and 
by sudden twisting or forcible 
extension of the forearm. 
Sprains involving the elbow 
joint are usually complicated by 
a similar injury to the superior 
radio-ulna articulation or vice 
versa. One of the four liga- 
ments helping to form the cap- 
sule may be torn, but the or- 
bicular ligament which holds 
the head of the radius in con- 
tact with the lesser sigmoid 
cavity of the ulna is rarely lac- 
erated, though it may be 
stretched and injured. 

SIGNS AND SYMP- 
TOMS are severe pain at the 
time the accident occurs; some- 
times producing faintness, nau- 
sea or even vomiting. Swelling 
with discoloration, pain on 




"> 0. — Tubeiv 111 ous d ison s 

movement and tenderness over alSo; Tk;;..\!"^ ^""^ ''"'^ " 



olbow. 



i" the 
obtuse 



230 INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 

certain parts of the joint are present. On account of this joint 
not being covered by much tissue, discoloration is an early sign. 

DIFFERENTIAL DIAGNOSIS : Tuberculous Disease oi the 
elbow joint is most common in young adults, showing itself by a 
slow, pale fusiform swelling, slight pain, limited movement, and 
in the later stages, muscular wasting and dilitation of the veins. 

COMPLICATIONS: Temporary Dislocations or Fractures of 
some parts of either the olecranon or coronoid processes ma}^ oc- 
cur and not be known unless an x-ray examination is made. If 
small particles of bone are broken off, impaired motion in flexion 
or rotation may result. 

Synovitis follows severe sprains to this joint and especially 
if there has been a complication, such as a fracture or a bad tear 
of any of the ligaments. If this inflammation becomes chronic, 
more or less impairment of motion results and ankylosis of the 
elbow joint proper or superior radio-ulna articulation may ensue 
and cause permanent disability and deformity. 

Suppurative Arthritis may result in a tuberculous joint or be 
due to other causes, such as pyemia, septic injury, etc. If this 
compHcation arises, disabihty is greatly prolonged and is not cov- 
ered by an accident policy, unless there is a straight history of an 
injury with evidence at the time the accident occurred and im- 
mediate and continuous disability. 

TOTAL DISABILITY following sprains of any of the joints 
of the elbow in preferred risks who require the constant use of 
the hands, such as telegraph operators, etc., lasts from 7 to 10 
days. In the same class of risks when the occupation is office and 
supervising, total disability should not be necessary for more 
than 2 to 5 days. Very severe sprains that are complicated by 
bad tears in the Hgaments or fractures which are not diagnosed, 
cause total disabihty of i to 3 weeks in preferred risks if the in- 
dividual requires the constant use of the hands. Ordinary risks 
are seldom totally disabled following slight sprains of this joint, 
but when severe, total disability may last from i to 3 weeks. 

PARTIAL DISABILITY is the usual indemnity demanded 
for sprains involving this joint, and preferred risks who do not 
require constant use of the hands generally ask for i to 2 weeks. 
Preferred risks such as stenographers, etc., are entitled to i to 3 
weeks of partial disability. Ordinary risks do not deserve any 
partial disabilitv. 



DISLOCATION OF THE ELBOW JOINT 



231 



EFFECTS : Unless a sprain of this articulation has been 
complicated by a more severe injury and permanent deformity 
and disability result, the risk is insurable for any form of insur- 
ance from one to two months after complete recovery. If anky- 
losis exists and is not marked, it would have no bearing on the 
insurability for accident insurance; even if the forearm is ankylosed 
at right angles with the arm, the individual might be considered 
for this form of policy by some accident insurance companies. 

DISLOCATION OF THE ELBOW JOINT 

INFORMATION: Dislocations of the elbow joint are said 
to occur next in frequency to those involving the shoulder joint. 
These injuries are generally caused by falls on the extended arm 



Humerus. 



Radius. 




Olecranon. 

Fig. 51. — Dislocation of both bones of the forearm 
backward. (Scudder). 



and hand and result in a great variety of dislocations; the most 
common of which is a displacement backwards of both bones of 
the forearm. The radius and ulna may also be displaced forward 
and to either side or each bone may be separately dislocated, the 
head of the radius being most often concerned in this injury. 
Direct force applied over the elbow, sudden twisting of the fore- 
arm and forcible elongation are also said to produce these dislo- 
cations. These injuries may be complicated by fractures of some 
of the processes entering into the formation of the joint, injury to 
the blood vessels and nerves and sonietimos by an opening which 
may extend from the joint to the external surface. 



232 INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 

SIGNS AND SYMPTOMS depend on the variety of dislo- 
cation. In all cases, however, there is much pain which produces 
weakness, profuse sweating and sometimes fainting at the time 
the accident is incurred; swelling quickly follows and marked dis- 
coloration of the tissues surrounds the elbow joint and extends 
up the arm and down the forearm; this appears within a short 
time. On examination it is ascertained the bones of the forearm 
are not in the normal position, being either placed posterior, an- 
terior, internal or external to the lower end of the humerus. If 
only one bone is dislocated, it is found out of its usual habitat, 
while the other one is. in its normal position. Function of the arm 
is lost, but slight motion may be present, flexion usually exists 
and shortening or lengthening of the forearm is present accord- 
ing to the character of the dislocation. 

DIFFERENTIAL DIAGNOSIS : Fractures of some of the 
processes of the bones entering into the formation of the elbow 
joint are frequent as complications and in some cases are very 
difficult of diagnosis. When a fracture exists in conjunction with 
a dislocation, there are additional signs and symptoms that may 
indicate this condition. If the individual is thin, crepitation be- 
tween the fragments can often be elicited, but the proper pro- 
cedure for diagnosing these condition is the use of the x-ray, 
which should always be employed when a dislocation or even an 
apparently severe sprain of this joint exists. Any injury to the 
elbow joint may result in permanent deformity and disability, and 
therefore a surgeon should employ every means within his power 
for the proper detection of all injuries that may have been sus- 
tained. It is impossible in a number of cases to properly diagnose 
these conditions without the use of an anesthetic, and this, to- 
gether with the x-rays should be used in practically aU cases. 

COMPLICATIONS: Fractures of the Bones or Processes en- 
tering into the formation of this joint are frequent. Some dislo- 
cations are more often compHcated with fractures than others, 
and when this condition exists, disabiHty is prolonged and is gov- 
erned by the time appHcable to the complication. 

Blood Vessels and Nerves are almost invariably torn and in- 
jured when a dislocation of both bones of the forearm occur. 
These comphcations are not so common when a dislocation of the 
head of the radius only is present. If the ulnar nerve 



SPRAINS OF THE WRIST JOINT 233 

is severely injured, paralysis of the forearm with loss of sensation 
may be present. 

Ankylosis of a more or less degree generally follows a dislo- 
cation of this joint and is caused by an effusion of blood inside the 
synovial membrane, which results in adhesions being formed and 
the bones bound together, thus producing this condition. 

TOTAL DISABILITY lasts from 2 to 4 weeks in preferred 
risks when the occupation requires daily use of the forearm. If 
the duties of the occupation do not require this use in the same 
class of risks, total disability generally lasts from 3 to 7 days only 
and is followed by a longer period of partial disability. Ordinary 
risks are totally disabled from 3 to 6 weeks as the result of this in- 
jury, when complications are not present. 

PARTIAL DISABILITY of i to 2 weeks is usually neces- 
sary in preferred risks requiring much use of the hands in the oc- 
cupation. When the duties are mainly directing, this partial dis- 
ability lasts from 2 to 4 weeks. Ordinary risks are seldom en- 
titled to any partial disability. 

EFFECTS : Dislocations of the elbow joint leaA^e impaired 
motion and a weakened arm which persists for months and some- 
times years. If the impairment or deformity is not sufficient to 
produce disability, and the individual is not prevented from pro- 
tecting himself if occasion requires, accident insurance can be 
safely written in the majority of cases from six to twelve months 
after the date of dislocation. There is no impairment for life or 
health insurance following this injury. 

SPRAINS OF THE WRIST JOINT 

INFORMATION: Sprains of this articulation are probably 
as frequently seen as are sprains involving any other joint of the 
body, and when a sprain is said to have occurred to the wrist joint, 
it means that the articulation between the lower end of the radius 
and ulna or the inferior radio-ulna articulation, the articulation 
between the lower end of the radius and ulna as a whole with 
the carpal bones — the radio-carpal articulation — or the articula- 
tion between the carpal bones and the bases of the meta-carpal 
bones, — the carpo-metacarpal articulation, — has boon injured. 
These three articulations are so closely allied ti> each other that 



234: INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 

a fall on the extended hand — which is the usual method of pro- 
ducing a sprain or a sudden twisting of the extremity — causes the 
injury to some parts of these joints; it is therefore impossible and 
impracticable to designate the particular articulation that is con- 
cerned in the sprain, the signs and symptoms being the same for 
all three, together with the length of total and partial disability. 

SIGNS AND SYMPTOMS: Sprains of the wrist joint are 
most frequently caused by falls; therefore an abrasion of the palm 
or back of the hand usually accompanies this injury and is appar- 
ent. The individual complains of pain in the joint which is ag- 
gravated by movement, sometimes redness, which disappears 
within twenty-four hours and a pronounced swelling to be fol- 
lowed by echymosis. On examination, tenderness is complained 
of at different points surrounding the joint; these places indicat- 
ing the tears in the ligaments and tissues. 

DIFFERENTIAL DIAGNOSIS: Acute Articular Rheuma- 
tism may begin in this articulation and may be coincident with a 
fall, and this may cause a claimant to think that the disability is 
due to a sprain and not to rheumatism. The diagnosis is easily 
made, rheumatism produces much swelling accompanied by red- 
ness which persists during the time the joint is involved, increased 
local heat and tenderness which is not in spots as in a sprain; in 
addition there is an increased body temperature, acid sweats, and 
later, the disease affects other articulations. 

Temporary Dislocations are often diagnosed as sprains. In 
these cases, the bones are dislocated by the injury and immedi- 
ately return to position, when the history following indicates a 
sprain and is usually and properly diagnosed as such. 

Fractures often complicate severe sprains of the wrist joint, 
and in miany cases are not diagnosed unless the x-ra3^s are used. 
Sprain or chip-fractures or fractures in which a ligament tears off 
a small particle of bone are frequent in this articulation, and so 
also are fractures of the carpal-bones, and usualty this condition is 
not known unless the above means are used for the diagnosis. 
When a fracture exists, there is crepitation and unnatural move- 
ment at the point of injury, and the fact that use of the hand is 
absolutely denied from the time of the accident, while in a sprain 
movement is present. If any of these signs cannot be elicited, the 
x-rays must be employed before the proper diagnosis can be made. 

Tuberculous Disease of this joint may be claimed as a sprain, 
but in this disease the swelling involves the joint and all the soft 



DISLOCATION OF THE WRIST JOINT 235 

tissues, it is spindle-shaped, no discoloration is present, impaired 
motion in the joint and those of the fingers exists and muscular 
atrophy of the forearm is marked. 




Fig-. 52. — Tuberculosis of the Wrist. (Moore). 

COMPLICATIONS: Dislocations and Fractures complicate 
these sprains and are described under Differential Diagnosis. 

Ankylosis may follow an injury to the wrist joint, but it sel- 
dom does when only a sprain has occurred; it being more com- 
mon after fractures or severe dislocations. 

TOTAL DISABILITY lasts from i to 3 weeks in preferred 
risks who require the constant use of the hands; in the same class 
if the injury is to the left hand and the occupation is office and 
supervising, total disability is short and only lasts from i to 3 days. 
Ordinary risks require from i to 3 weeks of this disability before 
they can return to their work; this time depending on the se- 
verity of the sprain. 

PARTIAL DISABILITY of i to 2 weeks is allowable to 
preferred risks following a sprain of either wrist without regard 
to the occupation. Ordinary risks are not entitled to partial dis- 
ability. 

EFFECTS : Sprains of this articulation are prone to recur, 
but as the cause is usually a fall, and this is not frequent, the in- 
dividual is insurable for any kind of insurance from one to two 
months after recovery, and unless there is a history of repeated 
sprains to the wrist joint, a waiver eliminating indemnity for this 
injury would not be necessary on an accident policy. 

DISLOCATION OF TFIE WRIST JOINT 

INFORMATION: As in sprains involving the wrist joint, 
so also in dislocations of this joint, three articulations mav 



236 



INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 



be concerned; one between the lower end of the radius and ulna, — 
the inferior radio-ulna articulation — one between these two bones 
as a whole, and the carpal bones themselves, — the radio-carpel ar- 
ticulation, and one between the carpal and metacarpal bones — 
the carpo-metacarpal articulation. The most common dislocation, 
however, is of the carpal bones forward or backward, the latter 
being the most frequently seen. These dislocations are usually 
due to falls on the palm of the hand or when the hand is flexed. 
Sometimes a dislocation may occur as the result of twisting or 
forcible extension. 

SIGNS AND SYMPTOMS are pain and swelling which 
marks the position of the carpal bones either above or below the 
lower ends of the radius and ulna, loss of motion in the articula- 
tion and much discoloration. On examination, the bones are not 
found in position, movement of the hand causes excruciating pain, 
and if an upward dislocation of the carpal bones exist, they are 
found on the upper surface of the radius and ulna. The length 
between the elbow and tips of the fingers is shorter than in the 
arm of the opposite side. 

DIFFERENTIAL DIAGNOSIS: Colics' Fracture at one 
time was considered to be a dislocation upward of the carpal bones 




Fig-. 53. — Deformity at the wrist consequent upon 
displacement backward of the lower fragment of 
the radius after fracture at its lower extremity. 
(Levis). 



of the wrist, but of course is now known to be a transverse or 
obUque fracture of the lower end of the radius, and swelling 



SPRAINS OF THE HAND AND FINGERS 237 

which it produces is known as the "silver-fork deformity." This 
fracture causes the hand to be adducted with some pronation. 
Crepitation is present and the styloid process of the radius does 
not occupy the same position in relation with the styloid process 
of the ulna as it does in a normal wrist. When a dislocation is 
reduced, it stays in position, while a fracture of this joint is es- 
pecially prone to recur when reduced, unless pressure is con- 
tantly made over the seat of injury. 

COMPLICATIONS: Stiffening of the wrist joint, with the 
same condition in the fingers and thumb may follow these dislo- 
cations, but this seldom becomes permanent. 

TOTAL DISABILITY lasts from 2 to 4 weeks in preferred 
risks such as musicians, machine type setters, etc., in the same 
class when the duties are ofihce and supervising, this form of dis- 
ability usually lasts from 3 to 10 clays only. Ordinary risks are 
totally disabled from 3 to 6 weeks, this time depending on the 
character of the dislocation and the amount of damage done to 
the ligaments at the time the bones get out of place. 

PARTIAL DISABILITY lasts from i to 3 weeks in pre- 
ferred risks in addition to the above; the length of time depend- 
ing on the exact duties of the occupation. Ordinary risks are 
rarely entitled to any partial disability. 

EFFECTS: When a wrist joint has once been dislocated, 
the same condition will recur with little force; therefore the joint 
is an impaired one and the individual is not insurable for acci- 
dent insurance without a waiver eliminating indemnity from this 
injury, unless two or three years have passed after the date of ac- 
cident, in which case the person is insurable for any kind of a 
poHcy. 

SPRAINS OF THE HAND AND FINGERS 

INFORMATION: Sprains involving the joints of the 
fingers or thumb are frequent and seldom cause total disability. 
while sprains of any of the joints of the hand are very unconunou. 
They are due to falls, blows, twists or any external violence which 
does not dislocate or fracture some of these bones. 

SIGNS AND SYMPTOMS are pain on niovomont. tender- 
ness surrounding the affected joint, slight redness which soon 
disappears, swelling, and kiter discc^loration. 



238 



INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 



DIFFERENTIAL DIAGNOSIS: Syphilitic Dactylitis is 
usually seen involving one of the joints of the fingers and is char- 
acterized by a slow swelling which becomes much greater than in 
a sprain, absence of pain and a purplish red discoloration. The 
condition of a finger already affected with this disease may be 
aggravated by a fall and result in a claim for a sprain of one of 
these joints. The pain, swelling and discoloration characteristic 



,.>^§V 




Fig. 54 Sj^philitic dactylitis. (American Text Book, Diseases 

of Children). 



1 
1 



of a sprain will soon subside, however, while the above condition 
will persist. Syphilitic dactylitis is a slow process and in time 
may cause ulceration. 

Rheumatoid Arthritis is an affection which frequently involves 
the joints of the fingers or thumb, and this condition may be 
claimed as the result of a sprain. This disease in the acute stages 
usually involves several joints at the same time or one joint may 
be repeatedly affected. It is characterized by a lateral enlarge- 
ment of the joints which are painful on movement, and this is soon 
followed by rigidity, deformity and a deposit of lime salts sur- 
rounding the articulation, tenderness on pressure is slight and 
redness of the joints is absent. 



DISLOCATIONS BETWEEN THE JOINTS OF THE HAND 



23^ 




Fig-. 55. — Deformity of arthritis deformans. (Lockwood). 

TOTAL DISABILITY lasts from 3 to 7 days in preferred 
risks when a sprain occurs to the fingers or thumb of the right 
hand and the occupation requires the constant use of the hand. 
The same class of risks are never totally disabled when the injury 
occurs to the left hand. Ordinary risks are not totally disabled 
from a sprain of the fingers or thumb, but sometimes when a 
number of joints of both hands are injured at the same time, total 
disability may last from 3 to 7 days. 

PARTIAL DISABILITY of i to 2 weeks is occasionally 
necessary in preferred risks when several joints have been 
sprained, and this is especially true if the injury occurs to the 
right hand. Ordinary risks are not often entitled to any partial 
disability unless the duties of the occupation require the use of 
the hands and the sprain has been severe, when i week is gener- 
ally sufficient. 

EFFECTS: None. 

DISLOCATIONS BETWEEN THE JOINTS OF THE HAND 
. AND FINGERS 



INFORMATION: Dislocations of the carpo-metacarpal 
joints, the metacarpo-phalangeal and of the i^halanges are fre- 
quently seen. These injuries may be produced l\v a sudden twist- 



240 



INJURIES TO THE JOINTS OF THE UPPER EXTREMITY 



ing or forcible bending forward or backward of the joints; the 
most frequent dislocations being those between the phalanges 
themselves and the metacarpo-phalangeal joint of the thumb. 

SIGNS AND SYMPTOMS are pain, tenderness, swelling 
followed by discoloration, loss of movement in the affected joint 
and evidence that the bones are not in their proper position. 




Fig-. 56. — X-ray dorsal dislocation of the 
first phalanx of the thumb. (Scudder). 



COMPLICATIONS : Fractures sometimes complicate these 
dislocations and are best diagnosed by crepitation, which is 
usually easy to elicit, and the use of the x-rays. Fractures pro- 
long disability somewhat when found in connection with these in- 
juries. 

TOTAL DISABILITY lasts from i to 2 weeks in preferred 
risks when the duties of the occupation require much use of the 
hands, such as telegraph operators, stenographers, etc.; in the 
same class when the injur)^ occurs to the left hand and the duties 
are ofifice and supervising, total disability seldom lasts more than 
I to 3 days. Ordinary risks may require from i to 2 weeks of 
total disability following a dislocation of the joints of the fingers 
or thumb, but this time is not often demanded, unless several 
joints are dislocated at the same time or the hand is otherwise 
injured. 

PARTIAL INDEMNITY of i week is allowable in some 
cases to preferred risks when the dislocation has occurred to the 



FRACTURES OF THE SCAPULA 241 

right hand and has badly lacerated some of the ligaments, and the 
occupation requires much use of the hand. In the same class 
when the injury occurs to the left hand and the duties are such 
as not to require the constant use of the hand, this form of dis- 
ability lasts from i to 2 weeks. Ordinary risks are not entitled 
to any partial disability. 
EFFECTS: None. 



PART III 

FRACTURES AND AMPUTATIONS INVOLVING THE UPPER 

EXTREMITY 

FRACTURES OF THE SCAPULA 

INFORMATION: The scapula is a bone which is seldom 
fractured, and when such an injury is received, it is almost in- 
variably due to direct force. Fractures of this bone may involve 
the body, the edges or some of its processes. 

SIGNS AND SYMPTOMS depend on the part of the bone 
fractured. The body of the bone being so well imbedded in the 
muscular tissue, fractures of that part or the borders are some- 
times hard to distinguish. Crepitation may be present with swell- 
ing and very extensive discoloration, pain on movement and es- 
pecially when the hand and arm is placed to the back and ten- 
derness over the point of injury. Fractures of the acromion pro- 
cess show flattening of the shoulder, with the injured shoulder on 
a lower level than the one on the opposite side, crepitation, local- 
ized pain and tenderness. Those involving the coracoid process 
are usually comphcated with fractures of other parts of this bone 
and are best diagnosed by means of the x-rays. 

TOTAL DISABILITY lasts from 4 to 6 weeks in preferred 
risks when the injury occurs to the right scapula and the constant 
use of the right arm is necessary in the occupation. In the same 
class of risks, if the injury occurs to the left scapula and the duties 
of the occupation are office and supervising, from 2 to 3 weeks 
are usually sufficient. Ordinary risks require from 4 to 8 weeks 
of total disability for a fracture involving any part of this bone. 
Compound fractures of this bone seldom occur to the body, but 
16 



242 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 



when the acromion process is broken, a compound fracture may 
result. Total disability, ho\vever, is not often increased by this 
complication. 




Fig. 57. — Multiple fractures of the scapula. Railroad 
accident. (Scudder). 

PARTIAL DISABILITY of i to 4 weeks is payabre to pre- 
ferred risks; this time depending on the exact duti-es of the occu- 
pation and the location of the fracture, whether involving the 
right or left scapula, the body of the bone or some of its processes. 
Ordinary risks are not entitled to any partial disability. 

EFFECTS : Fractures of the body of this bone seldom leave 
any permanent disability or deformity even though ununited. 
Fractures between the acromion process and the spine of the 
scapula, if properly united, also leave no permanent disability or 
deformity. If this fracture unites in a malposition, certain limita- 
tion of movement in the arm is present, btit hardly sufficient to 
have any bearing on the issuance of an accident policy. The in- 



FRACTURES OF THE HUMERUS 



243 



dividual is insurable for any kind of a policy from three to six 
months after complete recovery from any fracture involving any 
part of this bone. 

FRACTURES OF THE HUMERUS 




Fig. 58. — Fracture of the suigical neck 
of the humerous. (Scudcler). 



INFORMATION : Fractures of the humerus are frequently 
seen and most often involve the shaft of this bone, although either 
extremity or the processes connected with it may also be frac- 
tured. Such injuries generally 

result from direct force, but 
muscular action may produce 
these fractures. Fractures in- 
volving either extremity may 
extend into the shoulder or el- 
bow joints, thereby complicat- 
ing, the injury, greatly prolong- 
ing disability and resulting in 
impaired motion of the joint 
when recovery takes place. 
More ununited fractures result 
when the shaft of this bone has ^~ — 
been involved than in any other 
bone of the body. 

SIGNS AND SYMPTOMS: Severe pain follows a fracture 
of the humerus, with weakness, profuse perspiration, nausea, 
faintness, and in many cases, loss of consciousness. The pain is 

greatly increased on movement 
and is accompanied by tenderness 
and unnatural mobility at the 
point of injury; much swelHng of 
of arm follows with extensive dis- 
coloration. If the fracture has 
ruptured or is making pressure 
on the brachial artery, the radial 
pulse is absent. Injuries to either 
extremities show signs and symp- 
toms characteristic of the particu- 
lar part involved: if the sur- 
gical neck of the humerus is 

Fig. 59.— Fracture of the lower part fi-'irtn rod i^'iin ic fr'in<nii 1 1 t^l to 
of the shaft of the humerous. (Scudder). IiaLIUlLCU paUl Ls naUsUUlUa TO 




244 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 

the fingers on account of pressure on the brachial plexus; short- 
enmg may also be present and pronounced displacement evident. 
Fractures involving the lower extremities in which the condyles 
are broken off, show broadening of this end of the bone with crep- 
itus and movement at a point where it should not be present. 

DIFFERENTIAL DIAGNOSIS : Dislocations of the head of 
the humerus are sometimes hard to distinguish from fractures of 
the surgical neck. In dislocations the flattening of the shoulder 
is higher than in fractures. The head of the bone is in the axilla 
in a dislocation and can be felt to rotate with the humerus, while 
in a fracture it remains in its normal position and ceases to move 
when the arm is turned. In a fracture the false joint is below the 
shoulder, while with a dislocation, absence of movement in the 
usual position is evident. Examination with the x-rays makes the 
diagnosis positive. 

COMPLICATIONS: Arteries or Nerves may be injured in 
these fractures; if the former, the brachial artery may be so badly 
torn and circulation so interfered with, that amputation of the ex- 
tremity is necessary at once or within a few days after the acci- 
dent. When the nerves only are involved by pressure or lacera- 
tion, pain of more or less severity may be present and transmitted 
to the fingers and persist for an uncertain period. 

TOTAL DISABILITY lasts from 6 to lo weeks in preferred 
risks such as physicians, lawyers and others who require the daily 
use of both arms in the occupation. In the same class when the 
fracture involves the left humerus and the duties do not require 
the constant use of both arms, from 2 to 4 weeks are usually suffi- 
cient. Ordinary risks require from 8 to 12 weeks of total dis- 
ability following a fracture of this character. Fractures of either 
extremity of this bone involving the joint increase total disability 
I to 3 weeks, according to the severity of the fracture and the 
resulting deformity. When fractures of the shaft of this bone 
are ununited and an operation is necessary for wiring, total dis- 
ability is increased 4 to 6 weeks from the date of operation. Com- 
pound fractures of the humerus are not uncommon, and Avhen 
they exist, total disability is prolonged i to 3 weeks and softie- 
times longer in all classes. 

PARTIAL DISABILITY of i to 4 weeks is payable to pre- 
ferred risks when the duties require much use of both arms. In 
the same class of risks if the injury is to the left arm, partial dis- 
ability of 4 to 6 weeks may be necessary. Ordinary risks do not 



AMPUTATIONS OF THE UPPER EXTREMITY 



245 



often deserve any partial disability. Partial disability in all classes 
of risks in which the fracture has involved either the shoulder or 
elbow joint, is increased 3 to 6 weeks, and in some cases much 
longer. This is especially true when the fracture involves the 
elbow joint and much 'deformity results; motion being greatly 
impaired for a much longer period of time. 

EFFECTS : Following a fracture of this bone in which union 
has been good, the arm remains weak for a considerable period. 
This weakness, however, is not sufficient to cause disability, but 
obliges the individual to protect the affected arm. If non-union 
results for any cause and is permitted to exist, the individual 
would not be insurable for any kind of a policy. Following com- 
plete recovery of this fracture, insurance of any character may be 
safely written from six to nine months after the date of accident. 

AMPUTATIONS OF THE UPPER EXTREMITY 

INFORMATION: Amputations of the upper extremity 
may be made through some part of the arm or shoulder as the 




Fig. 60. — Amputation of the right arm, follow 
ig railroad injury. (Keen's Surgery). 



result of very severe injuries, such as mangling by railroad trains 
or machinery, \\nien it is necessary to renuue this extremity at 



246 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 

the shoulder joint on account of injuries received, the hemorrhage 
and shock have been so great that death generahy ensues in a 
short time. Amputations between the shoulder and elbow are 
often performed and a good recovery follows. When an indi- 
vidual carrying an accident policy suffers an amputation of the 
upper extremity within ninety days from the date of accident, the 
case is easily settled by the policy providing a specific sum for this 
loss. If both upper extremities are sacrificed, the policy usually 
pays the principal sum. Some policies pay weekly indemnity in 
addition to the above. If the amputation is not done in this time, 
the individual can claim total disability from the date of accident 
to the time that he can resume a part of his occupation; after 
which he may claim partial disability for the limit of his policy. 

SIGNS AND SYMPTOMS are characteristic of the kind of 
injury received. Much mangling and tearing of the arm is usually 
the result of a crushing force. The soft parts are badly lacerated, 
while the bones are broken in a number of places, the blood ves-~ 
sels torn and injured and the circulation destroyed below the 
point of injury; great shock is present with hemorrhage, pain and 
often unconsciousness. 

COMPLICATIONS : When an amputation through the hu- 
merus or the shoulder joint is necessary, it is seldom that other 
injuries do not complicate the case. These may be even more 
severe than the one requiring an amputation, but the length of 
disability is always governed by the most serious injury. 

TOTAL DISABILITY: If death does not occur at once, it 
may ensue within a few days from the date of accident. Should 
the individual recover, total disability in all classes of risks lasts 
from 8 to 14 weeks when the amputation has been made at or 
through the shoulder joint. If done lower down through some 
part of the humerus, this form of disability in all classes lasts from 
6 to 10 weeks. 

PARTIAL DISABILITY follows and is present during the 
remainder of the life of the individual. 

EFFECTS : Any one who has lost an arm is an impaired 
risk for accident insurance, and is not insurable for this form of 
policy, although life or health insurance may be safely written on 
such a person from six to twelve months after the date of accident. 
If both arms have been amputated, insurance of all kinds would be 
denied. 



FRACTURES OF THE RADIUS AND ULNA 247 

FRACTURES OF THE RADIUS AND ULNA 

INFORMATION: Fractures of the radius and ulna may 
involve one or both bones and may occur to the shafts of either 
bones or to their extremities. Colles' fracture is one of the most 
frequent fractures that occurs to the lower end of the radius and 
is described separately. Fractures of these two bones are gene- 
rally due to direct force. Indirect force and rarely muscular ac- 
tion may be the cause. 

SIGNS AND SYMPTOMS are pain at the point of injury 
which is aggravated by movement in any direction of the hand or 
forearm, tenderness, much swelling, with early and extensive dis- 
coloration. Unnatural mobility exists at the point of injury with 
crepitus and displacement. If the fracture is at either extremity 
of the bones pain in the joint on movement is complained of, with 




Shaft of 
iradius. 



Fig. 61. — Fracture of both bones of the 



248 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 

loss of motion at this point. Fractures of the olecranon process 
usually show a wide separation of the fragments and inabiUty to 
extend the forearm. If the fracture occurs at the neck of the 
radius, there is crepitation on pronating the forearm and loss of 
movement in the head of the bone on rotation of the forearm. 

COMPLICATIONS: Dislocations and Injuries to the nerves 
and blood vessels in the forearm complicate fractures of these 
bones. These complications manifest themselves by their charac- 
teristic signs and symptoms, and if these are not definite, a skia- 
graph will show the existing condition. 

TOTAL DISABILITY : If the injury involves the right fore- 
arm in preferred risks and the duties of the occupation require 
the constant use of the hands, the disability lasts from 4 to 6 
weeks; in the same class of risks when the injury is to the left 
forearm and the duties of the occupation are-ofhce or supervis- 
ing, total disability is not so long, lasting only i to 2 weeks. 
Ordinary risks are totally disabled, from 6 to 8 weeks following a 
fracture of either of these bones at any point. If the fracture in- 
volves any of the joints in connection with this part of the body, 
total disabihty is increased i to 3 weeks; this depending on the 
location of the fracture and the resulting union. Compound 
fractures of the radius or ulna increase total disability i to 3 
weeks in all classes of risks. If the fracture enters the joint in 
addition to being compound, total disability may be much pro- 
longed on account of the location of the break and the infection 
which follows. Such cases may require 3 to 6 weeks additional 
time. 

PARTIAL DISABILITY is necessary in addition to the 
above and lasts from i to 3 weeks in preferred risks who require 
the constant use of both arms. In the same class of risks follow- 
ing a fracture of the left forearm and the duties are not such as 
would require much use of the hands, partial disability lasts from 
4 to 6 weeks. Ordinary risks do not often require any partial dis- 
ability; sometimes, however, i to 3 weeks may be necessary. This 
form of disability is increased 2 to 4 or 6 weeks in all classes of 
risks in which a fracture extends into and involves any of the 
joints in connection with the forearm. 

EFFECTS: Fractures involving the upper extremity of 
either the radius or ulna usually produce permanent deformity, 
but not sufBcient to prevent the individual from securing all kinds 
of insurance as soon as recovery is complete. When the shaft of 



COLLES' FRACTURE 



249 



one or both bones has been broken, some impaired supination 
and pronation may result, but this is generally of little importance 
in relation to accident insurance. Insurance companies accept 
risks who have suffered from the above fractures for any kind of 
insurance from three to six months after comiplete recovery, un- 
less the deformity is so great that a certain amount of permanent 
disability is present, when an accident policy would hardly be 
issued. 

COLLES' FRACTURE 

INFORMATION : Colles' fracture is a transverse or oblique 
fracture of the lower end of the radius, usually occuri^ing from 
one-half to one and one-half inches above the articular surface of 
the lower end of this bone. If the fracture is markedly oblique 
and runs into the wrist joint, it is known as a Barton's fracture. 
Colles' fracture is very frequently seen and generally results from 
a fall on the extended hand. It often occurs as the result of back- 
firing in gasolene engines. 

SIGNS AND SYMPTOMS are pain that is said by the suf- 
ferer to be in the wrist joint and which is increased on movement 




Fig. 62. — Colles' fracture of the lower end of the radius. 
Lateral view showing silver-fork deformity. (Helferich), 

of the hand or fingers, tenderness and a ''silver-fork" deformity 
on the back of the wrist. This projection is caused by the mount- 
ing of the lower fragment on to the lower end of the upper frag- 
ment and is characteristic of this fracture. Pronation and abduc- 
tion of the hand is present, crepitation may be elicited when the 
bones are replaced in their proper position and extensive swell- 



250 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 



n 



ing and echymosis which invoh'es the lower end of the forearm 
and the hand, follow these injuries. The use of the x-rays con- 
firms the diagnosis and also shows if the bones are in proper posi- 
tion after reduction. 

COIMPLICATIOXS : Fracture of the lower end of the radius 
which is so oblique as to enter the wrist joint may produce more 
or less stiffening of this articulation. If this results from any 
cause it is generally a temporary condition, as the hand is so con- 
stantly used that perfect motion returns in time. 

TOTAL DISABILITY in preferred risks whose occupa- 
tion requires the constant use of both hands lasts from 4 to 6 
weeks. If the fracture occurs to the left wrist and the duties of 
the occupation are oi^ce, etc., preferred risks are not often totally 
disabled more than i to 3 weeks. Ordinary risks demand from 6 
to 10 weeks of this disabiHty for a fracture involving either radius. 
Colles' fracture is seldom complicated by an opening through the 
skin, but if such a condition exists, total disability is increased 
I to 3 weeks on account of the fracture being compound. 

PARTIAL DISABILITY of i to 3 weeks is allowable to 
preferred risks who require much use of the hands and the injury 
has occurred to the right forearm. AA'hen the fracture involves 
the left radius and a short period of total disability has follow'ed, 
preferred risks whose duties are mainly clerical, require from 4 
to 6 weeks of this disability. Ordinary risks are rarely, if ever, 
entitled to any partial disability. 

EFFECTS: Fractures in this situation are usually properly 
reduced and no deformity follows, the risk being insurable for 
all kinds of insurance from four to six months after the date of 
accident. If a deformity results from the fracture, permanent 
disability does not often ensue, and the partial disability or incon- 
venience due to stiffening and partial loss of motion is hardly 
sufficient to prevent the individual from securing accident insur- 
ance six months or more after the date of injury. 

AAIPUTATION OF THE FOREARM 

INFORIVIATIOX : Accidents that badly lacerate the tissues 
of the hand and forearm may result in amputations on account of 
this condition or interference with the circulation. Such injuries 
usually occur to ordinary risks and are caused by the hand and 
forearm being caught in machinery or between moving objects. 



FRACTURES OF THE CARPAL BONES 251 

AMien an individual becomes a claimant under an accident policy 
for an amputation of either arm below the elbow or both of them 
above the wTist joint, the policy usually provides a specified sum 
for such a loss and the length of total and partial disability is 
tmimportant. If this is not the case, the time as given generally 
covers the length of disability. 

SIGNS AND SYMPTOMS: Following a severe injury that 
might cause amputation, there is evidence of the hand and fore- 
arm being torn and lacerated, with more or less hemorrhage, 
great shock, pain and usually a number of contusions and other 
injuries to other parts of the body. 

COMPLICATIONS: Dislocations involving the elbow or 
shoulder joints or fractures of some of the bones of the upper ex- 
tremity are often seen in conjunction with injuries which result in 
amputations between the wrist and elbow joints; any other kind 
of an injury may also complicate such an accident. 

TOTAL DISABILITY in preferred risks lasts from 2 to 
4 weeks when the accident that causes an amputation of the left 
forearm is uncomplicated. In the same class of risks and under 
the same condition, if the injury occurs to the right forearm, total 
disability lasts from 4 to 8 weeks. Ordinary risks are totally dis- 
abled from 6 to 10 weeks following an amputation which is un- 
complicated by other injuries and which is performed on either 
forearm. Infection will prolong the above time i to 4 weeks. 

PARTIAL DISABILITY is present in all classes of risks for 
the remainder of the life of the individual. 

EFFECTS : Individuals who have sufifered an amputation of 
either hand or forearm below the elbow joint are impaired risks 
and are not often considered insurable for accident insurance. 
Life or health insurance, however, may be written on this class 
from six to twelve months after the date of accident. 

FRACTURES OF THE CARPAL BONES 

INFORMATION: Fractures involving one or more of the 
carpal bones are unfrequent and when present are usually not 
diagnosed unless the x-rays have been used. These fractures are 
due to direct, violent force which is sustained when a fall occurs 
and the weight of the body is thrown on the hyper-extended hand. 
These injuries are most frequently said to be sprains of the wrist, 
it being impossible in some cases to differentiate botwoon a sprain 
and a fracture, — unless a radiograph is made. Fractures of these 



I 



252 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 




Fig. 63. — X-ray fracture of 
scaphoid. A five-months' "sprained 
wrist." (Codman and Chase). 



bones when produced by machinery, etc., often result in com- 
pound comminuted fractures, and these often result in an am- 
putation. In such cases, accident insurance policies usually pay 
a certain sum for the loss of a hand at or above the wrist joint. If 
such an amount is paid for this kind of an accident, total and par- 
tial disability for the time the individual is disabled is not always 
allowed, although some policies pay weekly indemnity, in addition 
to a stipulated figure. 

SIGNS AND SYMPTOMS: After such an injury to the 
wrist, there is external evidence of the accident, sometimes an 
abrasion or swelling involving this part of the extremity and ex- 1 
tending up the forearm and down into the hands and fingers; pain 
and tenderness are always present, motion is impaired and in some 
cases crepitus can be obtained. These fractures are sometimes 
compound, Avhen the usual signs of such a fracture are present. 

DIFFERENTIAL DIAGNOSIS: Fractures of the Carpus 
and sprains of any of the joints between the lower end of the radius 
and ulna and the bases of the meta-carpal bones are extremely 

hard to diagnose. Fractures involv- 
ing more than one of the bones can 
usually be diagnosed b}^ aid of the 
fingers, but fractures involving one 
bone wath perhaps only a small part 
of a process broken off, are almost 
impossible to find without the use 
of the x-rays, and such injuries at 
first are frequently said to be sprains, 
but later on account of prolongation 
of disability a fracture is suspected. 
In a fracture crepitus can usually 
be obtained, and this is not present 
in a dislocation or sprain. Deform- 
ity exists with a dislocation at a 
joint, while with a fracture it is 
usually between the articular surfaces, although it may be close 
to a joint. Movement in a fracture which is not impacted is pres- 
ent, not so with a sprain, and if a dislocation, movement is lack- 
ing at a place where it should be secured. 

COMPLICATIONS: Compound Fractures of these bones 
almost invariably result in infection and stiffening of the wrist | 
joint, — if not in an amputation. This latter, however, is seldom " 



AMPUTATIONS THROUGH THE CARPUS 253 

performed unless the bones are so badly broken that circulation 
is interfered with or it is probable that on recovery, the hand and 
fingers will be so stiff and deformed that it is best to remove the 
part at once. 

TOTAL DISABILITY lasts from 3 to 6 weeks in preferred 
risks when a fracture occurs to the carpal bones of the right hand 
and is uncompHcated and the hand maist be constantly used. In 
the same class, if the carpal bones of the left hand are fractured 
and the duties of the occupation consist of ofhce and supervising, 
this disability lasts fromi 3 to 7 days only. Ordinary risks require 
from 4 to 8 weeks of total disability following a fracture which in- 
volves these bones of the wrist. Compound or comminuted frac- 
tures prolong disability i to 4 weeks, according to the severity 
of infection and the number of bones involved. If an amputation 
is performed, from 3 to 5 weeks are necessary for complete heal- 
ing of the parts after the date of operation. 

PARTIAL DISABILITY exists in preferred risks who re- 
quire the constant use of the hands and i to 3 weeks is the usual 
time in addition to the above total, when the injury has involved 
the right wrist. In the same class when the opposite wrist is in- 
jured and the duties of the occupation do not require extended 
use of the hands, from 3 to 6 weeks are necessary. Ordinary risks 
seldom deserve any partial disability. If an amputation is per- 
formed on account of the accident, partial disability is permanent 
and can be claimed for the limit as allowed by the policy, unless 
it provides a specified sum for the loss of a hand at or above the 
wrist as the result of accidental injury. 

EFFECTS : Motion is generally impaired following a frac- 
ture of any of the carpal bones, but on account of the hand being 
so frequently used, this impairment gradually disappears and in 
time perfect motion is obtained. Individuals with a history of 
such an accident are insurable from six to twelve months after the 
date of accident, unless an amputation has been performed when 
accident insurance would be denied such a person, but life or 
health insurance could be safely written. 

AMPUTATIONS THROUGH THE CARPUS 

INFORMATION: Amputations at the wrist joint or be- 
tween the bases of the meta-carpal bones and the inferior radio- 
ulnar articulation follow severe injuries to the hand and tinkers 



254 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 

which destroy the tissues to such an extent that recovery is im- 
possible; rarely is an amputation performed for a bad dislocation, 
but sometimes a compound comminuted fracture of the carpus 
may result in an amputation at the point of injury. Gunshot 
wounds involving the hand or fingers or wounds produced by 
explosion often require amputations. Insurance policies gener- 
ally pay a specified sum only for the loss of a hand at or above 
the wTist joint, but in some cases w^eekly indemnity is payable in 
addition. If both hands are lost at or above the wrist joint, the 
majority of companies pay the face of the policy, provided in any 
case that the operation for the removal of the hand or hands oc- 
curs within ninety days from the date of accident. 

SIGNS AND SYMPTOMS : After the hand has been taken 
off, the evidence is plain and indisputable and by comparing the 
two upper extremities, the line of amputation can be easily 
learned. If the case is seen before the hand is amputated, a 
bruised and lacerated extremity is evident. Shock is always pres- 
ent following an injury of such a character, with pain, hemorrhage, 
swelling of the upper arm and in some cases injuries to other 
parts. 

TOTAL DISABILITY lasts from 4 to 6 weeks in preferred 
risks when an amputation of the right hand takes place. If the 
left hand has been removed, the same class of risks demand from 
2 to 4 weeks of this disability. Ordinary risks are totally disabled 
from 4 to 8 weeks when either hand has been removed by opera- 
tion following an accidental injury. Infection of the stump pro- 
longs this disability i to 4 weeks in all classes of risks. If both 
hands or one hand and one foot are amputated, the face of the 
policy is payable to the insured. 

PARTIAL DISABILITY is present after an amputation of 
the hand and .persists during life. 

EFFECTS : Individuals having suffered the loss of a hand, 
are not insurable for accident insurance, but a life or health policy 
can be safely Avritten on this class, all other conditions being fav- 
orable. The loss of both hands would prevent any form of insur- 
ance being written. 

FRACTURES OF THE METACARPAL BONES 

INFORMATION: Fractures of the metacarpal bones of 
the hand are frequent; the metacarpal bone of the index finger 



FRACTURES OF THE METACARPAL BONES 



255 



being the one most often involved. These injuries are usually 
due to direct force, such as a blow on the palm or back of the 
hand, but sometimes indirect force such as a fall produces the in- 
jury. Compound fractures of these bones are not unusual. 

SIGNS AND SYMPTOMS: 
Swelling of the hand appears and 
is followed later by discoloration, 
with pain which is increased on 
movement or when the hand is in 
the dependent position and tender- 
ness over the injury. On examina- 
tion, the ends of the fractured 
bones are felt and crepitus is some- 
times elicited. Loss of power in 
the hand is present. 

TOTAL DISABILITY in 
preferred risks lasts from 2 to 4 
weeks when any of the metacarpal 
bones of the right hand have been 
injured and the occupation re- 
quires the constant use of the 
hand or fingers. In the same class 
when the fracture involves the 

left hand and the duties can be performed mostly by the right 
hand, total disability lasts from i to 5 days only. Ordinary risks 
require from 3 to 5 weeks of total disability following a fracture of 
these bones of either hand. If the fracture is compound and in- 
fection results, the above total disability in all classes of risks is 
prolonged i to 2 or 3 weeks. 

PARTIAL DISABILITY of i to 2 weeks is pa3^able to pre- 
ferred risks following an injury to the right hand. If the fracture 
involves the left hand in the same class, 2 to 3 weeks are generally 
sufficient. Ordinary risks are rarely entitled to partial disability. 

EFFECTS : These fractures generally unite with little or no 
deformity and no permanent impairment of the function of the 
hand, unless the fracture has involved the joints at either ex- 
tremity of the bones when slight stiffening may be the result. In- 
dividuals are therefore insura1)le for all kinds of insurance as soon 
as union is complete. 




Fig. 64. — Oblique fracture of the 
third and fourth metacarpal bones; 
X-ray tracing. (Scudder). 



256 FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 



FRACTURES OF THE PHALANGES 





INFORMATION : Fractures involving the phalanges of the 
fingers or thumb are frequent and are usually due to direct and 
violent force; not infrequently these fractures are compound. 

SIGNS AND SYMPTOMS are pain 
which is worse on movement in the af- 
fected finger and also when the hand is 
in the dependent position; swelling fol- 
lowed by discoloration, crepitus on mov- 
ing the fractured ends of the bones to- 
gether and deformity. 

TOTAL DISABILITY in preferred 
risks lasts from 2 to 4 weeks when the 
fracture involves one or more of the pha- 
langes of the right hand and the individual 
is right handed and must use the hand and 
fingers constantly in the occupation. In 
, the same class when the injury is to the 

^ left hand, total disabiHty is not often al- 

■t^ lowable. Ordinary risks demand from 3 

t^n|^ \ to 4 weeks of this disability for uncompli- 

cated fractures involving these bones. 
Compound fractures of the phalanges 
are frequent and total disability is in- 
creased I to 2 weeks in such cases. 
PARTIAL DISABILITY in preferred risks lasts from i to 
2 weeks when the accident has occurred to the right hand and the 
duties of the occupation require the use of that member. In the 
same class when the injury involves the left hand and no total dis- 
ability has been present, from 2 to 4 weeks of partial disability 
are necessary. Partial disability in preferred risks is prolonged i 
to 2 weeks when the fracture is compound. Ordinary risks are 
not entitled to this form of disabiHty. 

EFFECTS: Fractures of these bones usually unite without 
deformity. If the fracture involves one of the joints, more or 
less stiffening may result. Even in such cases, the risk is unim- 
paired for all kinds of insurance from three to six weeks after the 
date of accident. 



Pig. 65. — Lateral X- 
ray view of fracture of 
the shaft of the second 
phalanx of the middle 
finger. (Eisendrath). 



AMPUTATIONS OF THE PHALANGES 257 

AMPUTATIONS OF THE PHALANGES - 

INFORMATION : Amputations of the fingers or thumb fol- 
low severe injuries which mash or destroy the soft tissues and the 
bones so completely that removal of the part is necessary. These 
injuries are generally produced by machinery or catching the 
fingers or thumb between doors and frames of buildings, cars, etc. 
Some accident insurance policies pay a specified sum for the loss 
of a finger or thumb in addition to weekly indemnity, but the ma- 
jority of companies only pay weekly indemnity unless the claimant 
accepts a certain sum in lieu of this total or partial disability. 
When a claim for the loss of a finger or thumb or part of one is 
received, it should be thoroughly investigated. Malingerers select 
the fingers of the left hand — if they are right handed — for mutila- 
tion, and are never able to produce witnesses of the accident, al- 
though they may fill out a blank themselves under another name as 
a witness. These fraudulent claims are always presented under 
the double indemnity clause if possible, and in almost every case 
the claim can be settled for considerable less than it is worth, thus 
showing that the malingerer is willing to settle for any obtainable 
sum. 

SIGNS AND SYMPTOMS: Severe pain with nausea fol- 
lows the infliction of an injury that results in the amputation of 
these parts; there is evidence of the mashed finger or thumb and 
slight shock. Some other part of the hand or body may also be 
injured at the same time, producing the signs and symptoms pe- 
culiar to the part involved. 

TOTAL DISABILITY lasts from 2 to 4 weeks in preferred 
risks who require constant use of the hands when the amputation 
is performed on the fingers or thumb of the right hand. In the 
same class when the injury has occurred to the fingers or thumb 
of the left hand, total disability lasts from 2 to 5 days and is fol- 
lowed by a longer period of partial. Ordinary risks are totally 
disabled from 3 to 6 weeks when an injury to the hand results in 
an amputation of the fingers or thumb. If the injury is so exten- 
sive that one or more fingers are removed at the time of the oper- 
ation, total disability in all classes of risks is increased i to 2 
weeks beyond the above specified time. Infection almost invaria- 
bly follows in these cases, but the time is not prolonged thereby. 

PARTIAL DISABILITY of i to 3 weeks is necessary in 
preferred risks when the amputation has occurred to the right 



251 



FRACTURES AND AMPUTATIONS OF UPPER EXTREMITY 



hand, and from 3 to 5 weeks in the same class when some part of 
the left hand has been amputated and a short period of total dis- 
ability has preceded this time. Ordinary risks are not often par- 
tially disabled. 

EFFECTS : Amputations resulting in the loss of the end of 
one finger or a whole finger, produce no impairment of the risk. 
If several fingers have been lost in, this manner, and especially if 
the thumb has been amputated, the risk may not be insurable for 
accident insurance, but each case must be considered separately. 
Life or health insurance can be safely written as soon as the parts 
are completely healed. 



CHAPTER XI 

ACCIDENTS AND DISEASES INVOLVING THE LOWER 

EXTREMITIES 

PART I 

INJURIES TO THE SOFT TISSUES 

ABRASIONS AND CONTUSIONS OF THE HIP 
AND THIGH 

INFORMATION: Abrasions of the hip or thigh usually 
occur in conjunction with other or more severe injuries to differ- 
ent parts of the body. Contusions in this location may not be 
accompanied by any other injury unless it be an abrasion. Both 
abrasions and contusions result from direct force violently ap- 
plied, such as a severe fall or when the body is caught between 
moving objects. These injuries usually involve the soft tissues 
only; sometimes, however, a hard fall will produce an injury to 
the acetabular cavity of the os innominata by driving the head of 
the femur against the articular surface of this cavity. 

SIGNS AND SYMPTOMS are slight swelling with exten- 
sive discoloration and stiffness in the muscles which prevents 
movement without much pain; tenderness is always present and 
Vvhen the injury has involved the head of the femur and its articular 
cavity, there is deep seated pain, inability to raise or stand on 
the injured leg and severe pain on the slightest movement. 

COMPLICATIONS: Tuberculous Disease of this joint may 
be present in the latent stage and a severe contusion set up an 
active inflammation, when the signs and symptoms would be the 
same as for a contusion, except that the evidence of the accident 
would not disappear, but on the contrary the inflammatory symp- 
toms would increase and be followed by an elevation of the tem- 
perature and in some cases abscess formation. Differential diag- 
nosis and complications are more fully considered under Sprains 
of the Hip Joint. 

259 



260 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

TOTAL DISABILITY is rarely deserved in abrasions in- 
volving this part of the body unless complicated with some other 
or more severe injury. Contusions which injure the soft tissues 
only and are very severe in character, produce total disabihty of 
2 to 7 days in all classes of risks. Total disability may last from 
I to 2 or 3 weeks in severe contusions which result in the forma- 
tion of a hematoma and infection of the same. Contusions result- 
ing in an inflammation involving the head of the femur, require 
from 2 to 4 weeks of total disability in all classes of risks. 

PARTIAL DISABILITY is never deserved in uncompli- 
cated abrasions, but 2 to 7 days may sometimes be allowed in 
contusions which prevent an individual from doing the accus- 
tomed amount of outside work. 

EFFECTS: None, unless the injury has involved the head 
of the femur. In such cases when total disability has lasted any 
length of time, there may be a suspicion that some disease exists 
in this cavity. If the disability has been caused by the accident 
alone, all kinds of insurance can be written as soon as recovery 
is complete, but if it is thought a tuberculous disease is present, 
the individual would not be insurable for any kind of a policy. 

i COXTUSIOXS OF THE KNEE JOINT 

INFORMx\TION : Contusions of the knee joint are fre- 
quent and usually result from falls in which the body alights on 
the bended knee or the joint is caught between hard objects and 
squeezed. As this is the most complicated joint of the body and 
has the greatest number of ligaments in connection with it, con- 
tusions and also sprains cause longer periods of disability when it 
is injured than when the same degree of injury occurs to some of 
the other joints. 

SIGNS AND SYMPTO^IS: After a contusion has been 
sustained to this part of the body, swelling follows in the connec- 
tive tissue surrounding the joint and within twenty-four to thirty- 
six hours fluid is usually effused inside of the articulation. Pain 
of more or less severity is complained of and this is aggravated by 
putting weight on the injured foot, tenderness generally exists 
over the whole articulation, but is more pronounced in spots and 
discoloration ensues within twent3^-four hours when the superficial 
tissues have been the most severely injured. If the damage is 
deep seated, discoloration does not appear until after one to two 



CONTUSIONS OF THE KNEE JOINT 261 

or three days. Palpation shows fluid inside of the articulation 
and later as this fluid becomes absorbed, grating is elicited on 
movement. 

DIFFERENTIAL DIAGNOSIS : Charcofs Joint is an os- 
teo-arthritis occurring in individuals suffering from locomotor 
ataxia. The knee joint is the one most frequently involved i-n this 




FIG. 66. — ClfARCOT'S JOINT. (Eisendrath). 
The illustration shows the enormous enlarge- 
ment of the lower end of the femur as a result 
of trophic disturbances and the ability to produce 
abnormal abduction in the knee-joint. 

disease which is often sudden in onset accompanied by little, if 
an}^ pain, and unconnected with any injury. The swelling of Char- 
cot's joint is very extensive and characterized by an eft'usion inside 
of the joint, no discoloration exists and great range of move- 
ment is present with deformity and sometimes dislocation. ]\Ius- 
cular atrophy also occurs in the muscles of the leg and thigh. 

Hysterical Joint is most common in women and frequently af- 
fects the knee. In this affection, pain and tenderness are com- 
plained of, the skin is hyperesthetic, muscles generally rigid and 
the joint held in a fixed position. SwelHng or discoloration does 
not exist in this condition and effusion is also absent. Sometimes 
at intervals, the joint may be red and hot, but the characteristic 
discoloration of an injury never appears. 



262 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

COMPLICATIONS: Dislocation of either of the semi-lunar 
cartilages may take place in a severe contusion; in which case the 
period of disabihty is prolonged. 

Sprains of this joint often complicate contusions and are 
best indicated by spots of tenderness over the location of the liga- 
ments that are torn and lacerated. 

TOTAL DISABILITY in preferred risks whose duties are 
performed in a sitting position, seldom lasts more than 2 to 3 
weeks in severe contusions to the knee joint, while slight contu- 
tions require from 5 to 10 days only of this disability. When the 
occupation requires the upright position or much walking, total 
disability lasts from 2 to 4 weeks in the same class of risks follow- 
ing a severe contusion, and from i to 2 weeks when the injury 
has not been severe. Ordinary risks are totally disabled from i 
to 2 weeks from sHght contusions to this joint and from 3 to 4 
weeks when the injury has been more serious. 

PARTIAL DISABILITY of i to 3 weeks is payable to pre- 
ferred risks when the duties of the occupation are performed in- 
side. If the duties are performed in the upright position, partial 
disability of 2 to 4 or 5 weeks is sometimes necessary to this class 
of risks following a severe contusion to the knee joint. Ordinary 
risks are seldom entitled to partial disability. 

EFFECTS : Insurance companies rarely make any change 
in a policy when a policy holder has suffered from a severe con- 
tusion to the knee joint and has recovered in a reasonable time. 
But if an individual with a history of a severe contusion in which 
disability has lasted for some time would apply for accident in- 
surance, a company would hardly issue such a policy until at 
least from three to six months after complete recovery had taken 
place. Such an accident has no bearing on a life or health policy. 

INCISIONS AND LACERATIONS OF THE HIP OR 

THIGH 

INFORMATION : Incisions and lacerations involving the 
hip or thigh are not often seen except in ver}^ severe injuries in 
which serious complications exist. Long, deep or transverse in- 
cisions involving this part of the body result in disabihty; while 
slight, superficial cuts cause inconvenience only. Lacerations of 
the hip or thigh do not often occur under personal accident poli- 
cies, but are met with in liabilitv examinations. Severe lacera- 



INJURIES OF THE HIP OR THIGH 263 

tions that are unaccompanied by other injuries may cause dis- 
abihty in all classes of risks. 

SIGNS AND SYMPTOMS : Incisions and lacerations of the 
hip or thigh produce pain, swelHng, hemorrhage and evidence of 
a cleanly cut wound or a torn, lacerated one. Dirt and other 




Fig. 67. — Severe lacerated wound of the left thigh with loss of soft tissues. 

(Keen's Surgery). 

particles are usually found in lacerated wounds and infection al- 
most invariably occurs. If the laceration has been extensive and 
deep or an incision has been transverse arid severed some of the 
muscles of the thigh, loss of power in the leg is evident. Infec- 
tion is very frequent in this class of wounds and prolongs dis- 
ability. 

TOTAL DISABILITY in all classes of risks requiring much 
walking or standing on the feet, lasts from i to 2 weeks when the 
incision has been longitudinal and deep. If it is transverse and 
severed some of the muscles, total disability lasts from 2 to 3 
weeks in all classes. Superficial lacerations involving the immedi- 
ate underlying tissues only, produce total disability of 3 to 7 days 
in all risks. Deep lacerations that are almost invariably followed 
by infection, require from i to 2 weeks of total disal^ility in pre- 
ferred risks. Ordinary risks are totally disabled from 2 to 3 week? 
in this class of injuries. Deep incisions or lacerations which mav 
occur to the inner side of the thioii and wouiul some of the im- 



264 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

portant blood vessels or nerves may increase the above time 2 
to 4 weeks when an operation is performed. 

PARTIAL DISABILITY of i to 2 weeks is payable to pre- 
ferred risks following incisions which have caused a short period 
of total disability. Severe lacerations which have resulted in a 
more or less extended period of total disability in preferred risks, 
require from i to 3 weeks of partial when the occupation of the 
individual requires that the erect position be maintained during 
business hours. Ordinary risks are not often entitled to partial 
disability following either incisions or lacerations; when allow- 
able I to 2 weeks may be granted. 

EFFECTS : A scar results from this class of wounds, but 
produces no deformity or disability. If the injury has involved 
some of the important blood vessels or nerves of the thigh and 
an operation is performed, the result of this would govern the in- 
surability of the risk. Ordinarily, individuals are insurable for 
any kind of insurance as soon as recovery is complete after the 
above injuries. 

PUNCTURED WOUNDS OF THE HIP OR THIGH 

INFORMATION : Punctured wounds involving the soft 
tissues of the hip or thigh are produced by any sharp-pointed in- 
strument and also result from missiles that are driven into the 
tissues by explosives. Gunshot wounds may be complicated by 
an injury to the bones of the pelvis, the femur or some of the in- 
ternal organs of the lower part of the abdomen. Punctured 
wounds involving these parts also result from animal bites and 
are invariably infected. If the animal is not rabid, the wound 
heals in the same length of time as an ordinary infected wound. 
Superficial punctured wounds to this part of the body which are 
not very deep or numerous, seldom produce any disability in any 
class of risks. 

SIGNS AND SYMPTOMS: Pmictured wounds involving 
the soft tissues are evident and are followed by pain, swelling, in- 
fection and a discharge of pus. If the puncture is due to a gun- 
shot injury and involves the soft tissues only, the signs and symp-' 
toms are the same as the above. AMien a bone is fractured there is 
additional evidence of such a condition. Should the puncture be 
complicated by an injury to some of the contents of the lower part 
of the abdominal cavity, signs and symptoms peculiar to the in- 



PUNCTURED WOUNDS OF HIP OR THIGH 265 

jury supervene. If it is not possible to diagnose a fracture or in- 
jury to some of the bones of the hip or thigh when the puncture 
has been caused by a bullet, the use of the x-rays is necessary and 
the diagnosis is then easily made. 

COMPLICATIONS: Fractures involving the bones of the 
pelvis or the femur as the result of gunshot injuries, greatly pro- 
long the periods of disability, but this time depends on the char- 
acter of the wound, its location and severity. 

Hydrophobia may follow and develop within a few weeks or 
may be delayed as long as one to two years. If this disease su- 
pervenes, the result is fatal in all cases; therefore an insurance 
company always attempts to make an early settlement of a claim 
arising from an animal bite. Should the disease occur and be fol- 
lowed by death ninety days or more after the date of injury and 
the company had not secured a release from the individual in- 
jured, it is questionable if there would be any liability on the part 
of the company for the payment of even weekly indemnity, as the 
policy provides that the disability must be immediate and con- 
tinuous, and ninety days or more after the injury could hardly be 
construed as conforming to these conditions. 

TOTAL DISABILITY does not often follow superficial 
punctured wounds when due to animal bites or sharp-pointed in- 
struments. If the wound has been deep and is followed by infec- 
tion, preferred risks whose occupation requires considerable 
walking may be totally disabled from i to 2 weeks. Ordinary risks 
are seldom totally disabled. Gunshot wounds to the hip or thigh 
in preferred risks result in total disabiHty of i to 3 weeks when 
the soft tissues only are injured and infection follows. If the 
bullet fractures some of the bones of the pelvis or femur, total 
disability is governed by the length of time required for the re- 
covery of the more severe injury or the fracture involving one or 
more bones and this is usually from 8 to 12 weeks in all classes 
of risks. 

PARTIAL DISABILITY follows in preferred risks who 
have suffered from superficial punctured wounds which become in- 
fected, and lasts from i to 2 weeks. Ordinary risks are not often 
entitled to any partial disability from this class of injuries. Gun- 
shot Avounds that have produced a long period of total disability in 
preferred risks require from 2 to 4 or 6 weeks of partial. Ordi- 
narv risks do not often demand partial disability following gun- 



266 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

shot wounds, for the reason that they do not return to work until 
all the duties of the occupation can be resumed. 

EFFECTS: Punctured wounds which involve the soft tis- 
sues only, heal with a resulting scar and no permanent deformity 
or disability. Gunshot wounds which fracture the femur or other 
bones may result in deformity and partial disability and the indi- 
vidual is then not insurable for an accident poHcy, although life 
or health insurance ma}^ be safely written on such persons after 
complete recovery. 

BURNS AND SCALDS OF THE HIP OR THIGH 

INFORMATION: When the hip or thigh is burnt or 
scalded the injury is usualty severe, for the reason that these 
parts are protected by clothing and the agent which causes the 
burn or scald gets under the clothing and is confined; thereby 
producing a much more serious injury than on the exposed sur- 
faces of the body. These burns are generally due to hot liquids, 
acids, steam or molten metal, and are more frequently seen in or- 
dinary risks and those whose occupation is very hazardous. 

SIGNS AND SYMPTOMS depend on the cause of the in- 
jury and the extent of surface involved. If the parts are scalded 
by hot steam or boiling liquids, blisters may form or the scald may 
be so severe that the parts are destroyed and sloughing occurs; 
these burns are usually superficial and involve a considerable area. 
Molten metals, acids and caustic alkalies burn deeply, and in some 
cases when the burn is caused by an overheated piece of metal, 
the parts are carbonized. Pain, swelling, tenderness and shock 
always accompany severe burns or scalds and suppuration follows 
almost invariably. 

TOTAL DISABILITY lasts from i to 2 weeks in preferred 
risks when the burn or scald is superficial and involves an area 
of two to four inches in diameter. In ordinary risks, the same 
kind of injury will cause total disability of 2 to 3 weeks. In mod- 
erately severe burns or scalds in which the area involved is of 
considerable extent or deep, total disability lasts from 3 to 5 weeks 
in preferred risks. Ordinary risks under the same conditions are 
totally disabled from 4 to 6 weeks. Very severe burns which are 
deep or cover a large area of the hip or thigh result in total dis- 
ability to all risks of 6 to 12 weeks or more, depending on the 
agent which causes the injury and also the tissues destroyed. In 



ABRASIONS AND CONTUSIONS OF THE LEG 267 

these very severe burns operations for skin grafting are neces- 
sary, but usually an attempt is made to encourage the formation 
of new skin during the above period of disability; if this is not 
done, each operation for this piu'pose prolongs total disabihty 2 
to 3 weeks in all classes. 

PARTIAL DISABILITY is payable to preferred risks fol- 
lowing all degrees of burns and scalds involving these parts and 
lasts from 2 to 4 or 8 weeks; the usual time, however, being from 
I to 3 weeks. Ordinary risks are not often entitled to partial dis- 
ability,, but some individuals insured under this class require this 
form, and may be partially disabled the same length of time as 
preferred risks. 

EFFECTS : Scars always follow burns and scalds in which 
the deep layers of the skin have been destroyed, and in time these 
cicatrices contract and result in deformity and sometimes perma- 
nent disability. This is especially true when a large area of sur- 
face has been involved and some of the underlying muscular tis- 
sues have been destroyed. Unless the deformity produces a cer- 
tain amount of permanent disability or hinders the movement of 
the individual to a more or less extent, the risk is insurable for 
all kinds of insurance from three to six months after complete 
recovery. Even if an accident policy cannot be written, life or 
health insurance may be granted. 

ABRASIONS AND CONTUSIONS OF THE LEG 

INFORMATION : Abrasions and contusions of the leg. in- 
cluding abrasions over the patella, are very frequent, and the 
length of disability depends on the location of the injury. In- 
juries to the anterior surface of the leg produce total and partial 
disability of a longer time than do the same kind of accidents in- 
volving the posterior surface or calf of the leg. The reason for 
this is that in accidents to the anterior surface, the bone itself is 
injured, it being protected in this situation only by its own cov- 
ering and the skin. Abrasions to this part of the Inxly as the re- 
sult of an accident, most often involve the anterior surface. If the 
abrasion is produced intentionally, the surface on the internal and 
anterior aspect of the leg is most often selected. Accidental abra- 
sions, however, are almost invariably (lee]HM-, narrower and more 
severe than self-inflicted ones. Fraudulent claimants more fre- 
quently select this part of the bcKly iov the purpose oi producing 



268 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

abrasions than perhaps any other. These abrasions are made 
by various means, such as confining an irritating substance or 
fluid over the internal and anterior surface of the leg, the use of 
sand paper or any rough object that will superficially destroy the 
skin, which is abraded over a broader and longer surface than if 
the result of an accident. After the skin is once broken, any cor- 
roding or irritating metal or poison can be applied when a violent 
localized inflammation results. Individuals suffering from varicose 
veins or having suffered from ulcers of the leg in which the skin 
has formed, but is very tender, are extremely liable to become dis- 
abled as the result of very slight injuries, and when these occur, 
disability is greatly prolonged on account of the previous condi- 
tion of the leg. Abrasions involving the posterior surface of the 
leg which is unimpaired by previous disease or injury, heal rapidly 
and seldom produce disability of any kind. Physicians in exam- 
ining cases for insurance companies in which an abrasion is the 
cause of disability, cannot use too much care in this class of in- 
juries. 

SIGNS AND SYMPTOMS: Evidence of the abrasion or 
contusion is apparent, and when the abrasion is on the anterior 
surface it is usually complicated by a bruise iuA'olving the under- 
lying bone, when severe pain is present, especially at night, and 
this is made worse unless the mdividual remains in the recumbent 
position. Contusions also produce pain which answers the above 
description if the injury involves the bone; swelling and discolora- 
tion follows all abrasions and contusions. These injuries occur- 
ring to the posterior surface of the leg produce signs and symp- 
toms as above described, with the exception that they are much 
less in severity. 

DIFFERENTIAL DIAGNOSIS: Accidental Abrasions in- 
volve the upper, middle or lower third of the anterior surface of 
the leg, and when seen the abrasion is generafly deep, narrow, 
and from one to two or three inches in length. There is usually 
some discoloration of other parts of the leg, and also small scat- 
tered abrasions. The individual complains of pain on walking 
and a throbbing pain at night. These abrasions are ver}^ slow 
in healing, the scab sometimes remaining two to four weeks or 
more. Self-inflicted abrasions are usually to one side of the mid- 
dle line and consist of an abraded surface of two to four or six 
inches in length and one to two inches in breadth. These abra- 
sions are superficial only, barely rupturing the skin. Severe pain 



ABRASIONS AND CONTUSIONS OF THE LEG 269 

is never complained of and the injury heals within one to two 
weeks, the malingerer claiming this time only for disability. 
When these self-inflicted abrasions are aggravated by binding a 
corroded copper cent against the tissue, there is evidence of a vio- 
lent circumscribed inflammation which is not present in an acci- 
dental abrasion. Self-inflicted abrasions, when infected suppurate 
at a number of points, while an abrasion received accidentally 
usually suppurates at its centre or the part which is most badly 
injured. Fraudulent claimants allege in many cases that they only 
carry one accident insurance policy, but this is always an untruth, 
and investigation reveals a number of accident policies as being 
in force. If possible, they claim that the injury occurred on a 
trolley car or under a condition in which double indemnity is 
payable, and invariably the claimant is alone at the time the so- 
called accident occurred. 

COMPLICATIONS: Infection commonly follows abrasions 
involving this part of the lower extremity, and always prolongs 
disability. 

Periosteitis frequently results from an abrasion or contusion 
to the anterior surface of the leg, and in some cases goes on to 
suppuration and requires an incision for evacuation of the pus. 
Such a condition prolongs disability and the length of time re- 
quired for recovery of this complication is covered by an insur- 
ance poHcy. 

Ulcers are often seen as a complication following an abrasion 
of the leg to any part of its surface. These ulcers are due to the 
fact that the skin is in an unhealthy condition and the slightest 
scratch or abrasion results in an ulcer that is extremely hard to 
heal. In these cases, the leg shows evidence that the same con- 
dition has existed previously. Ulcers may sometimes result when 
an abrasion ruptures a varicose vein. If disability is prolonged 
by an ulcer as the result of either of these compHcations, it is ques- 
tionable if an insurance company is liable for this disability. If it 
could be proved that the varicose condition was existing at the 
time the policy was applied for or that previous ulcers had been 
present and no mention of these facts were made in the applica- 
tion, the company could decline the claim on the grounds of 
^'breach of warranty" and have suPhcient cause to defend its ac- 
tion. 

TOTAL DISABILITY: Abrasions involving the posterior 
surface of the leg seldom cause any disability unless a varicose 



270 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

\em is ruptured or an ulcer forms, when total disability in all 
classes of risks may last from i to 2 or 4 weeks. This time may 
not be covered by the policy on account of fraud in omitting to 
state the existence of such a condition on the application for in- 
surance. Contusions in the same place may require from 3 to 7 
days of total disability in individuals whose occupation requires 
the erect position. Abrasions or contusions involving the an- 
terior surface of the leg in which the underlying bone has been 
injured, require from i to 3 weeks of total disability in all classes 
of risks; this time depending on the exact duties of the occupation. 
Superficial abrasions or contusions to the anterior surface involv- 
ing the skin and muscular tissue only, cause total disability of 2 
to 5 days in individuals whose occupation requires much walking'. 
Fraudulent claims alleging disability as due to an abrasion seldom 
demand indemnity for over i or 2 weeks, and of course are never 
entitled to any. 

PARTIAL DISABILITY is not often deserved in abrasions 
and contusions which involve the sides or posterior surface of the 
leg. When total disability has existed previously, from i to 2 or 
3 weeks are sometimes necessary following these injuries and the 
abrasion or contusion has involved the anterior part of the leg. 
Individuals on whom an ulcer forms after an abrasion or contusion 
may require partial disability of 2 to 4 or 6 weeks, — if the com- 
pany is liable for indemnity. 

EFFECTS : Superficial abrasions and sHght contusions to 
any part of the leg below the knee leave scars only. If the abra- 
sion or contusion has been severe and injured the anterior surface 
of the tibia, necrosis of the bone may ensue, but as this is a remote 
condition, the individual is insurable for all kinds of insurance 
as soon as recovery takes place. 

INCISIONS AND LACERATIONS OF THE LEG 

INFORMATION : Incised and lacerated wounds of the leg 
below the knee are frequent. Incisions to this part of the body do 
not cause much disability unless a number of deep cuts exist at 
the same time. Fraudulent claims alleging disability as due to 
incisions to the leg not uncommonly occur. Lacerated wounds 
are more often met with than incisions, and in some cases this 
class of wounds is nothing more than deep and severe abrasions. 
Disability is much longer if these wounds involve the anterior sur- 



INCISIONS AND LACERATIONS OF THE LEG 271 

face of the leg with an injury to the underlying bone, than if the 
posterior or lateral surfaces are wounded. 

SIGNS AND SYMPTOMS: Pain either accompanies or 
follows the infliction of incised or lacerated wounds; there is 
bleeding, swelling, and when the wound is an incision and has 
been deep, separation of the wound edges occurs, while in a lacer- 
ation the edges are torn and uneven. Lacerated wounds are es- 
pecially prone to infection, and if the laceration or incision has 
been deep and transverse, some impairment of motion may result. 
If the tendo Achilles is severed in an incision, partial loss of exten- 
sion of the foot results. 

DIFFERENTIAL DIAGNOSIS: Fraudulent Claims alleg- 
ing disability to be due to incisions show a number of superficial 
cuts on the inside of the leg starting from the lower extremity and 
running upward and backward. These cuts sometimes are noth- 
ing more than mere scratches. Very rarely does the incision ex- 
tend deeper than the skin, while incisions that are received acci- 
dentally and result in disability, are deep and require sutures for 
bringing the edges in apposition and may be found on any part of 
the leg, more frequently the outer surface and extending trans- 
versely or obliquely across. Self-inflicted incisions may be in- 
fected by the use of some poisonous substance as rubbing a piece 
of brass or copper over the wound; in which case only a part of 
the incision is primarily infected, and generally the part which 
is not involved heals without showing evidence of this condition. 

COMPLICATIONS : Deep Incisions and Lacerations occur- 
ring to the anterior surface of the leg may cut or destroy the 
periosteum of the tibia and result in infection and prolonged dis- 
ability. Incisions near the knee or ankle joint may enter these 
articulations and be followed by infection and partial or complete 
ankylosis. 

TOTAL DISABILITY following severe incisions or lacera- 
tions in preferred risks lasts from i to 2 weeks, when the individual 
must remain standing or walking the greater part of the day. In 
the same class of risks when the occupation permits a sitting posi- 
tion, from 3 to 7 days are sufficient. Ordinary risks are not often 
totally disabled more than i week in this class of injuries unless 
the wounds are very deep and extensive, when from 2 to 3 weeks 
are sometimes necessary. If an incised or lacerated wound is on 
the anterior surface of the leg and is complicated by an injury to 
the bone or its covering', total disabilitv is increased in all classes 



272 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

I to 2 weeks. If either of these wounds enter the knee or ankle 
joint and are followed by infection, total disability may last from 
3 to 6 weeks. 

PARTIAL DISABILITY is the most usual form of indem- 
nity payable following incised or lacerated wounds involving this 
part of the body and i to 3 weeks is the time generally demanded 
in all classes. If the injury is on the lateral or posterior surface 
of the leg, both forms of disability are shorter than if the anterior 
surface is involved. 

EFFECTS : Deep incisions or severe lacerations leave scars, 
but this does not impair the risk for any form of insurance. When 
the tendo Achilles has been severed and extension of the foot is 
lost, the risk is not insurable for an accident poHcy, but may be 
considered for life or health insurance. 

PUNCTURED WOUNDS OF THE LEG 

INFORMATION: Punctured wounds involving the leg, 
knee or ankle joint are usually due to animal bites or the result of 
gunshot injuries. These punctures ma}^ also be caused by a 
sharp-pointed object entering the tissues, such as nails, pitchforks, 
splinters, etc. This class of wounds involving the soft tissues of 
the leg only do not cause much disability, but when the knee or 
ankle joint has been entered, infection invariably occurs and dis- 
abiUty is greatly prolonged. Gunshot wounds to the articulation 
of the knee or ankle are serious injuries and leave permanent de- 
formity and disabihty; — if they do not cause an amputation. 

SIGNS AND SYMPTOMS depend on the character of in- 
strument causing the puncture. In all cases, however, there is a 
point of entrance and when the wound is a perforating one the 
point of exit is apparent; bleeding is present, with swelling and 
redness surrounding the opening in the skin. Sometimes a part 
of the instrument causing the wound remains and when due to 
gunshot injuries, powder may be imbedded in the skin around 
the opening. Shock is present in all gunshot injuries and is more 
severe when the missile enters the knee or ankle joint. Infection 
usually follows in these cases and not only greatly prolongs dis- 
ability, but in many cases causes loss of motion in the joint. Punc- 
tured wounds involving these articulations present signs and 
symptoms of a joint injury; pain is more severe on movement, 
and if the w^ound is in the knee or ankle joint, a discharge of syno- 



PUNCTURED WOUNDS OF LEG 



273 



vial fluid may be noticed. If either of the bones of the leg are 
fractured by the instrument causing the puncture, there is evi- 
dence of such injury; unnatural mobility, crepitus, splintering of 
the bone and inability to rest any weight on the foot of the in- 
jured side. Animal bites show marks of the teeth on each side 
of the wound and sometimes the tissues are torn out. 

COMPLICATIONS: Complete or Partial Fractures of the 
tibia or fibula follow gunshot injuries when the missile strikes the 




Fig-. 68. — Skiagraph of knee-joint showing wound 
by Remington bullet which traversed joint and 
lodged in upper end of the tibia. (American 
Text Book of Surgery). 

bone. Disability in such cases is greatly prolonged and deformity 
usually results and in many cases permanent shortening of the leg. 
Joint Injviries are the most serious complications in- connec- 
tion with punctured wounds, and this is especially true if the 
knee joint has been involved. This articulation is the most com- 
plicated one of the body and if the instrument \vhich causes the 
puncture enters it, disabilit}^ is greatly prolonged by succeeding 
infection. If the puncture is due to a gunshot wound and the 
bullet destroys some of the inij^ortant Hgamonts inside the joint, 
18 



274 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

this with the resuhing synovitis invariably leaves more or less im- 
pairment of motion. Punctured Avounds involving the ankle joint 
v/hich are followed by infection and diminished movement, often 
recover fairl}^ Avell on account of the constant motion which is 
present as the individual walks. 

Hydrophobia may follow an animal bite to this or any other 
part of the body, and when it is suspected that the bite is from a 
rabid animal of any kind, the Pasteur treatment should be taken 
at once. For other information concerning this complication, 
see description of H3^drophobia. 

Septicemia sometimes follows apparently simple punctured 
wounds; the infection of course entering the tissues at the time 
the puncture is made and not developing until later, when the 
wound becomes tender and painful. Infection of the lymphatics is 
indicated by red Hues extending up the leg and thigh and indura- 
tion of the glands of the groin which are tender and painful. Ir- 
regular fever with loss of appetite and sleeplessness, are some of 
the signs and symptoms indicating this complication. 

TOTAL DISABILITY in all classes of risks is practically 
the same, with the exception that in some preferred risks whose 
duties are performed at the desk, the period of total disability is 
I to 2 weeks shorter. Simple punctured wounds involving the 
soft tissues of the leg when uncomplicated except by infection, 
seldom cause any total disability. The same class of wounds en- 
tering the knee or ankle joint and followed b)'- infection, produce 
total disability of 2 to 4 weeks according to the joint injured and 
the degree of infection. Gunshot wounds involving the soft tis- 
sues of the leg require from i to 3 weeks of total disability. If 
either bone is involved, from 6 to 10 weeks may be necessary. 
When the knee joint is injured by explosives or bullets, total dis- 
ability lasts from 6 to 10 or 14 we^ks. Punctured wounds to the 
ankle joint when due to gunshot injuries cause total disability of 
6 to 10 weeks. 

PARTIAL DISABILITY lasts from i to 2 or 3 weeks fol- 
lowing a;iimal bites which occur to the soft tissues of the leg only. 
Individuals who have suffered from a gunshot wound involving 
the bones of the leg or the knee or ankle joint, require from 2 to 
4 or 6 weeks of partial disability according to the location of the 
injury, the duties of the occupation and the resulting deformity 
or impairment of motion. 

EFFECTS : Punctured wounds which do not injure the 



BURNS AND SCALDS OF THE LEG 275 

joints or bones of the leg, leave no permanent deformity or dis- 
ability. If the joints have been entered or the bones fractured, 
there may be permanent deformity and disability, but unless this 
is so extensive that the individual would be handicapped in per- 
forming the duties of his occupation or protecting himself when 
necessary, insurance of all kinds could be written from three to 
six months after recovery. 

BURNS AND SCALDS OF THE LEG 

INFORMATION: Burns and scalds occurring to either of 
the lower extremities below the knee are usually seen among ordi- 
nary risks, and especially those who work in foundries or where 
metal of any kind is reduced to the liquid state. These injuries 
are severe, for the reason that the molten metal splashes on the 
parts and burns through the clothing and is then confined. Steam 
and hot water also causes severe scalds to these parts. 

SIGNS AND SYMPTOMS: If the burn or scald has been 
extensive, shock is always present; in addition there is pain, ten- 
derness, redness and swelling of the parts which are either cov- 
ered by blisters or sloughing. The destruction of the skin and 
muscles occurs by carbonization, when overheated metals come in 
contact with this or any other part of the body. 

COMPLICATIONS: Acid Burns or those from molten 
metal sometimes penetrate either the knee or ankle joint, when 
infection follow^s and stiffening or complete ankylosis of the joint 
is the result. When these complications occur, disability is 
greatly prolonged and permanent deformity and impairment of 
the risk is the usual outcome. 

TOTAL DISABILITY in preferred risks suffering from su- 
perficial burns or scalds of the leg in which an area not more than 
one to three inches in diameter is involved, lasts from 5 to lo 
days. Ordinary risks with the same degree of burn require from 

1 to 2 weeks. Moderatel}^ severe burns with a considerable area 
of skin destroyed or a number of small deep burns, require from 

2 to 4 weeks of total disability. Ordinary risks under the same 
conditions demand from 3 to 6 weeks. Very deep burns or scalds 
which have caused much sloughing of the tissues in all classes 
of risks require from 6 to 12 weeks of total disability. 

PARTIAL DISABILITY of i to 2 or 4 weeks usually fol- 
lows burns of all degrees of severity, the time depending on the 



276 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

occupation, severity, location of the injury and the area of tissue 
destroyed. 

EFFECTS: All burns and scalds leave scars and when the 
cicatrix is large and depressed, contraction follows and in many 
cases permanent deformity and disability is the result. These 
scars when situated on the lateral and posterior surfaces of the 
leg do not often cause permanent disability, but when found in 
connection with the knee joint or the anterior or lateral surface 
of the ankle joint, contraction may be so pronounced that perma- 
nent deformity and impairment of motion results and the indi- 
vidual is unable to walk properly. Such cases are impaired risks 
and are not insurable for accident insurance, but a life or health 
policy may be safely issued from three to six months after com- 
plete recovery. Burns and scalds to the leg which leave scars 
only, permit insurance of all kinds to be issued as soon as recov- 
ery takes place. 

ABRASIONS AXD CONTUSIONS OF THE FOOT AND 

TOES 

INFOR]\IATION : Abrasions seldom occur to the foot or 
toes unless the individual is barefooted for some reason or other; 
this part of the body being protected the greater part of the time 
by shoes. Contusions are incurred when heavy articles such as 
trunks, boxes, etc., fall on these parts. Contusions are also sus- 
tained by knocking the bare foot or toes against an object in the 
dark. Abrasions resulting from the continued rubbing of a shoe 
against the foot are not accidental in origin and are not covered 
by an accident poUcy. If disability results from such a cause and 
a general health or disability policy is carried, then indemnity is 
payable for the loss of time resulting from such a condition. 

SIGNS AND SYMPTOMS: Abrasions unless severe pro- 
duce practically no symptoms and only an abraded surface which is 
accompanied by slight bleeding and followed by scabbing. Con- 
tusions are followed by pain, tenderness, considerable swelling 
and extensive discoloration which sometimes involves all the toes 
or foot after a moderately severe blow has been received. Pain is 
made worse by walking or in any position in which weight is put 
on the injured member. If the force of the blow producing the 
contusion has been severe enough to rupture the skin of the toes 
or foot, there is evidence of such. Discoloration under the nails 



INCISIONS AND LACERATIONS OF FOOT 277 

of the toes occurs, the same as under the nails of the fingers or 
thumb. 

TOTAL DISABILITY in all classes of risks suffering from 
abrasions of the foot or toes seldom follows unless the duties of 
the occupation require constant walking, when i to 3 days may 
be necessary if the injuries are very numerous and deep. Contu- 
sions involving the toes or foot in which much swelling and dis- 
coloration occur and wdiich border closely on sprains of some of 
the joints of the foot, require from 3 to 7 days of total disability 
m all classes of risks. If the contusion ruptures the skin of the 
toes or foot, total disability in preferred risks last from i to 2 
weeks. Ordinary risks require from 2 to 3 weeks. 

PARTIAL DISABILITY is the usual form of indemnity de- 
manded following abrasions and contusions of the foot, and pre- 
ferred risks require from i to 2 weeks, depending on the severity 
of the injury and the exact duties of the occupation Ordinary 
risks are not often entitled to this form of disability. 

EFFECTS: None. 

INCISIONS AND LACERATIONS OF THE FOOT 
AND TOES 

INFORMATION: Incisions involving the foot or toes do 
not often occur, except when the individual is not wearing shoes 
for some reason or other. Lacerations follow severe injuries to 
the foot in which that member is caught between hard objects and 
twisted, torn or mangled. Mutilation of the foot by cutting or 
chopping off a part of one of the toes is not uncommon among 
malingerers. 

SIGNS AND SYMPTOMS : Incised wounds of the foot pro- 
duce pain, bleeding, suppuration of the wound edges, and if the 
incision has been sufficiently deep and severed some of the ten- 
dons, loss of flexion or extension is present in the muscles in- 
volved. Lacerations of the foot or toes wdien produced by ma- 
chinery are followed by severe pain, tenderness, hemorrhage, 
much swelling, discoloration and mangling of the tissues. These 
cases are almost invariably badly infected at the time the injury 
occurs and are followed by suppuration which greatly prolongs 
disability and results in permanent deforniity or an amputation 
of some of the parts involved. Nausea, often vomiting, weakness, 
and sometimes fainting, immediatelv follow these injuries. A 



ff^ 



278 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

certain degree of shock is also present when the laceration of the 
toes and foot has been extensive. 

DIFFERENTIAL DIAGNOSIS : In fraudulent claims only 
a small part of a toe is intentionally amputated and mutilation is 
usually confined to one of the four outer toes, the great toe of 
the foot seldom being injured in this manner. Fraudulent claim- 
ants are sometimes seen suffering from a mutilation of a toe in 
which one or more toes of the same foot have been lost. If the 
foot on the opposite side is examined, the same condition is 
usually present. These claimants often allege that the accident 
occurred under conditions which would double the indemnity and 
witnesses are never present. Sometimes evidence of an amputa- 
tion of part of the fingers of either hand is also seen and is 
claimed to have been caused by an accident. 

COMPLICATIONS: Infection invariably follows lacerated 
wounds of these parts and is a common complication of incised 
wounds. If the laceration has been severe and some of the toes 
or foot are so badly injured that an amputation is necessary, a 
deformed foot is the result and some degree of permanent dis- 
ability ensues. 

TOTAL DISABILITY following incisions to the foot or 
toes depends on the occupation of the claimant and the location 
of the incision. Incised wounds in all classes of risks, on the up- 
per surface of the foot or toes running longitudinally, require 
from 3 to 7 days of total disability. When the incision is trans- 
verse and some of the extensor tendons severed, total disability 
lasts from 2 to 3 weeks in all classes. Longitudinal incisions of 
the plantar surface of the foot demand from i to 2 weeks of total 
disability in all risks. If the incision is transverse and some of 
the flexor tendons of the toes have been severed, total disability 
lasts from 2 to 4 weeks in all claimants. Infection in these cases 
prolongs the above time i to 2 weeks, and if an operation is done 
for suturing the severed ends of the tendons together and is per- 
formed immediately after the accident, this period of disability is 
not increased. Moderately severe lacerations involving the toes 
only require i to 2 weeks of total disability in preferred risks. Or- 
dinary risks demand from i to 3 weeks under the same condition. 
If the laceration is severe and involves the foot, total disability in 
preferred risks lasts from 2 to 4 weeks. Ordinary risks require 
from 4 to 6 weeks following these severe lacerations. If an am- 
putation of any part of the foot is performed, disability is pro- 



PUNCTURED WOUNDS OF FOOT AND TOES 279 

longed according to the time described under amputation of the 
particular part. 

PARTIAL DISABILITY in preferred risks lasts from i to 
2 weeks following incisions which have severed some of the ten- 
dons or moderately severe lacerations. Severe lacerations which 
have caused a considerable period of total disability may require 
from 2 to 4 or 6 weeks of partial disability in preferred risks. Or- 
dinary risks do not often ask for partial disability, but if the occu- 
pation requires considerable walking and the claimant is insured 
under this classification from 2 to 4 weeks of this form of dis- 
ability may be demanded. 

EFFECTS : Incisions and lacerations to the foot or toes in 
which the tissues have not been destroyed or the tendons sev- 
ered, leave no permanent deformity or disability; the risk being in- 
surable for all kinds of insurance as soon as recovery is complete. 
If the incision divides some of the tendons and loss of motion re- 
sults or the laceration causes permanent rigidity of some of the 
joints, the individual may not be insurable for an accident policy, 
but usually such a condition is not sufUcient for withholding this 
form of insurance. Should the laceration result in an amputation 
of some of the toes or part of the foot, it would be necessary to 
consider each case separately. 

PUNCTURED WOUNDS OF THE FOOT AND TOES 

INFORMATION : Punctured and perforating wounds of the 
foot in which the point of entrance is on the plantar surface, are 
generally due to stepping on some sharp object, such as nails, 
tacks, pins, etc. Punctured wounds of the toes from the under 
surface are usually caused by pins and needles. Gunshot wounds 
involving the foot or toes most frequently show the point of en- 
trance from the upper surface, as these injuries are often due to 
the accidental discharge of firearms, the bullet passing through 
the extremity of the individual holding the gun or revolver. These 
wounds are almost invariably infected, and in many cases tetanus 
supervenes. In punctured wounds of the foot which are almost or 
entirely healed in one or two weeks and are followed by tetanus, 
producing an extended period of total or partial disability and in 
many cases resulting in death, the question of Hability is an im- 
portant one. 

SIGNS AND SVMPTOIMS: In punctured wounds on the 



«C 



280 INJURIES TO SOFT PARTS OF LOWER EXTREMITY 

plantar surface, the point .of entrance is evident, and if the instru- 
ment passes entirely through the foot, its exit is seen on the upper 
part. There is pain, tenderness, swelling and inability to rest 
weight on the foot without increased pain. Gunshot injuries pro- 
duce nnore severe signs and symptoms, including evidence of con- 
tusion and laceration to the parts. Fractures of the bones of the 
foot frequently follow this class of injuries, when there is crepitus 
on movement and other signs of a break in the continuity of the 
bone involved. Sometimes a part or the whole of a toe is shot 
ofT as the result of a discharge of firearms. More or less shock 
accompanies this class of injuries; the severity depending on the 
constitution of the individual. 

COMPLICATIONS: Infection is almost sure to follow a 
punctured wound of any kind involving the foot or toes; the de- 
gree of this depending on the micro-organisms which gain access 
to the circulation through the opening accidentally produced. On 
account of the rarity of a punctured wound to the foot or toes 
not being infected, the length of total and partial disability as 
given implies this form of infection. 

Tetanus is very common following punctured wounds to this 
part of the body and is due to the bacillus of tetanus which gains 
entrance to the circulation at the time the injury is inflicted. The 
period of incubation for this germ is about two weeks; therefore 
the disease does not show itself until about that time; in the mean- 
while the prim.ary injury may have entirely healed. If this dis- 
ease ensues after a punctured wound, total disability is increased. 
If an insurance company has paid total or partial disability for a 
punctured wound and has secured a release, it is hardly possible 
that any court would rule that the company is still Hable, if an- 
other period of total or partial disability ensues or death results 
from this complication. Liability in cases where a release has not 
been obtained and this disease follows and causes disability or 
death, may be denied by an insurance company, — if the disabihty 
has not been continuous from the date of accident. Insurance 
companies, however, usually look at this complication in a broad 
light and pay for the full length of time disability results, counting 
from the date of accident up to and including the duration of the 
complication. 

TOTAL DISABILITY in all classes of risks lasts from i to 
3 weeks from a punctured wound occurring to the plantar surface 
of the foot. Gunshot wounds require from 2 to 4 weeks of this 



BURNS AND SCALDS OF FOOT AND TOES 281 

disability, and if a bone has been fractured, from 4 to 6 weeks are 
necessary. When a gunshot injury fractures a bone of the foot in 
preferred risks, total disability is sometimes i to 2 weeks less than 
the above. If an amputation of any part of the foot or toes is 
performed, see amputation of these parts. 

PARTIAL DISABILITY of i to 3 weeks is allowable to 
preferred risks following these injuries, the length of time de- 
pending on the occupation of the individual. Ordinary risks are 
not often entitled to any partial disabiHty, as it is necessary for 
them to be completely recovered before returning to work. 

EFFECTS : If tetanus does not follow the injury and recov- 
ery ensues without permanent disability or deformity of the foot, 
the individual is insurable for all kinds of insurance from three to 
six months after the date of accident. Should tetanus supervene 
and recovery follow from this disease, the individual would hardly 
be considered insurable for any kind of insurance until one year 
after the accident. 

BURNS AND SCALDS OF THE FOOT AND TOES 

INFORMATION : Burns and scalds of the foot and toes are 
usually the result of steam, molten metals or boiling liquids gain- 
ing access to the surface of the skin under the clothing and run- 
ning down into the shoes and confined there. These injuries are 
generally very severe on account of this condition and most fre- 
quently occur in ordinary risks whose occupation requires them 
to handle liquid metals or work where steam and hot water are 
used. 

SIGNS AND SYMPTOMS: Severe pain immediately fol- 
lows infliction of a burn or scald, with great swelling which ne- 
cessitates removal of the shoe by cutting it awa}^ Blisters and 
sloughing follow scalds from hot liquids or steam, while destruc- 
tion of the tissues ensues after contact with molten metal. There 
is tenderness and inability to rest any weight on the injured foot, 
together with shock which is present in the majority of cases. 

COMPLICATIONS: Severe and Deep Burns involving this 
part of the extremity may result in some of the tendons being de- 
stroyed or the toes so badly burnt that amputation results. One 
of the numerous joints may be opened by the injury when infec- 
tion and stiffening- follow; contraction of the scar tissue which 



ikiaak Ji 



282 INJURIES TO JOINTS OF LOWER EXTREMITY 

forms after these severe burns or scalds always leaves some de- 
formity and limits motion in the foot or toes. 

TOTAL DISABILITY lasts from i to 2 weeks in all 
classes of risks when the burn is superficial and extends over a 
small area on the anterior surface of the foot. Moderately severe 
burns involving the plantar surface require from 2 to 4 weeks of 
this disability. Deep burns to any part of the foot in which de- 
struction of tissue occurs, require from 6 to 10 weeks of total dis- 
ability; this time depending on the exact location of the injury, 
the degree of severity and any complications which may ensue. 
Burns or scalds involving the toes only, seldom cause total dis- 
ability longer than i to 2 wxeks in all risks. 

PARTIAL DISABILITY is payable to preferred risks in 
addition to the above and from i to 4 or 6 weeks are necessary; 
this time depending on the duties of the occupation. Ordinary 
risks do not often ask for this form of disability. 

EFFECTS : A scar always results from a burn, and if the 
injury has been at all severe, it may be adherent to some of the 
tendons or underlying tissue, and as it contracts, deformity and 
limitation of movement follow. If these injuries are not so severe 
that deformity and permanent disability results, the individual 
would be insurable for any kind of a policy from three to six 
months after complete healing of the injured surface. Burns or 
scalds resulting in such great deformity that permanent disability 
follows, would preclude the individual from obtaining accideiit 
insurance, but a life or health policy could be safely issued when 
recovery is complete. 



PART II 

ACCIDENTS TO THE JOINTS OF THE LOWER EXTREMITY 

SPRAINS AND DISLOCATIONS OF THE PUBIC AND 
SACRO-ILIAC ARTICULATIONS 

INFORAIATION: Sprains or dislocations involving the ar- 
ticulations between the two pubic bones in front or between the 
sacrum and the ilium behind, do not occur frequently, and if seen 



PUBIC AND SACRO-ILIAC JOINTS - 283 

are the result of a crushing force, such as results when the body 
is run over by a heavy vehicle or caught between moving objects. 

SIGNS AND SYMPTOMS : External evidence of the injury 
is usually apparent, although sometimes an automobile will pass 
over an individual and leave no visible evidence. If the injury is 
a sprain, pain is complained of in the injured articulation and this 
is made worse by movement in any direction of the lower extremi- 
ties, resting the weight of the body on them or by pressing the 
sides of the pelvis together. There is tenderness on pressure 
over the pubic or sacro-iliac joints and swelling which is followed 
by discoloration. 

DIFFERENTIAL DIAGNOSIS : Tuberculosis of the Sacro- 
iliac Joint may exist and be aggravated by a fall or twist in which 
a sprain involving this joint occurs. Tuberculosis in this situation 
is uncommon, and wdien present, usually affects young adults. 
Pain, swelling and redness are complained of, but no discoloration 
as is seen in acute injuries. Apparent lengthening of the limb on 
the diseased side exists and is not present in a sprain. Disability- 
as the result of an accident to an already diseased joint would not 
be covered by an accident policy. 

COMPLICATIONS: Dislocations of the pubic bones pre- 
vent the individual from standing in the upright position, there 
is a range of movement of about an inch at a place where a joint 
should not exist. Sacro-iliac dislocations almost never occur 
without more serious injuries. 

Fracture of some of the bones forming the pelvis or the 
coccyx is not unusual after this class of injuries and is best diag- 
nosed by means of the x-rays.. Injury to some of the organs of 
the abdomen, such as a rupture or contusion of the bladder or 
some of the other contents, frequently occurs at the time the ac- 
cident happened. If these internal injuries complicate sprains or 
dislocations of these joints, the signs and symptoms characteristic 
of the part injured follow immediately after the accident. 

TOTAL DISABILITY of 2 to 6 weeks is necessary in 
sprains or dislocations of these joints; this time depending on 
the number of ligaments torn and the degree of severity. If the 
pubic articulation is badh^ injured, wiring of the bones together 
may be necessary, when total disability will continue 4 to 6 weeks 
after the date of operation. 

PARTIAL DISABILITY is payable to preferred risks after 
severe sprains or dislocations of these articulations and ma}' last 



284 INJURIES TO JOINTS OF LOWER EXTREMITY 

from 2 to 4 weeks. Ordinary risks are not often entitled to any 
partial disability, for the reason that the length of total disability 
is long and the individual does not return to work until fully able 
to do so. 

EFFECTS : Uncomplicated sprains or dislocations involv- 
ing these joints leave no untoward effects and the individual is 
insurable for any kind of insurance from one to two months after 
the date of recovery. If fractures or injury to some of the internal 
organs complicate these injuries, each case must be considered 
separately and all kinds of insurance must be denied the individual 
until it is known positively that recovery has been complete, and 
this cannot usually be ascertained until after a careful medical ex- 
amination has been made. 

SPRAIN OF THE HIP JOINT 

INFORMATION: This articulation is a ball-and-socket 
joint and the head of the femur fits into the cavity of the pelvis 
so perfectly and is so well covered by muscular tissue that sprains 
of this articulation seldom occur. These injuries are produced 
by falls, forcible inversion or eversion of the leg, extreme flexion 
or hyper-extension of the thigh. 

SIGNS AND SYMPTOMS : History of an accident m which 
the leg has been violently moved as above described, together 
with pain and tenderness in the joint, form the basis for the diag- 
nosis of a sprain in this joint. Swelling may be so deep seated 
that it is not evident and discoloration so late in appearing that 
the diagnosis must be made long before. Inability to move the 
hip or thigh or rest any weight on the injured side without great 
pain is always present. 

DIFFERENTIAL DIAGNOSIS : Rheumatism may first at- 
tack this joint, when all the tissues surrounding the articulation 
are exceedingly painful; there is redness, localized heat, increased 
body temperature and the slightest movement in any direction 
causes excruciating pain. If this disease exists with a history of 
an accident which might cause a sprain, by waiting a short time 
some of the other joints of the body will be involved and then the 
diagnosis is easily made. 

Titberctdosis is more frequent in this articulation than in any 
other joint of the body; it is more common in children, but is 
sometimes seen in adults. Traumatism is sriven bv some authors 



SPRAIN OF THE HIP 



285 



as a probable cause of this disease, but from the fact that it is due 
to a specific micro-organism any injury of the kind that would 
produce the disease could in no way ingraft the bacillus of tuber- 
culosis inside the joint, it would seem that hip joint disease could 
not possibly arise as the result of an accidental injury unless tuber- 
culosis was existing in some other part of the body. This disease 




Fig-. 09. — Position in hip-joint disease, sidi 



(Fowler). 



is usually described under three stages, and if claimed as the result 
of a sprain or contusion, it would be seen in the second or third 
stage and the differential diagnosis at this time iKMween an injury 
and this disease should not be difficult. Hip jmnl disease is al- 
ways accompanied by swelling, nmscular wasting, pain in the joint 
which is worse at nio'ht and when the leii' i-^ nunod. slii^ht tender- 



286 



INJURIES TO JOINTS OF LOWER EXTREMITY 



ness on pressure, and if partial ankylosis has occurred, tilting of 
the pelvis follows on flexion and extension of the thigh. Should 
the disease go to the formation of an abscess, this is generally 
situated in front of the joint, when the usual signs and symptoms 
of such a condition manifest themselves. 




Fig. 70. — Position in hip-joint disease, rear view. (Fowler). 



COAIPLICATIONS : Fractures of some part of the femur 
may complicate a sprain of this joint, and if such a case is met 
with, the length of disability is governed by the more severe in- 
jury. 



DISLOCATIONS OF THE HIP 287 

TOTAL DISABILITY in preferred risks following a sprain 
of this articulation lasts from i to 3 weeks. Ordinary risks are 
usually totally disabled 2 wxeks, although this time may be ex- 
tended to 3 to 4 weeks; this depending on the severity of the 
sprain and the occupation of the individual. 

PARTIAL DISABILITY of i to 3 or 4 weeks is payable to 
preferred risks whose occupation requires much walking or the 
standing position. Ordinary risks are rarely entitled to partial 
disability. 

EFFECTS: None; the individual being insurable for all 
kinds of insurance as soon as recovery ensues. 

DISLOCATIONS OF THE HIP 

INFORMATION: The hip joint is the best example of a 
ball-and-socket joint in the body, and dislocations are not frequent 
on account of the almost perfect apposition of the head of the 
femur with the acetabular cavity and the great strength of the 
capsular ligament of this joint which is reinforced by the inverted 
Y shaped ligament. The large and strong muscles which sur- 
round this joint assist in keeping the head of the bone in posi- 
tion. These dislocations may occur in different directions; the 
most common, however, are those which go upward and back- 
ward, backward, downward, and inward; the first of which is 
known as the dislocation of the dorsum of the ilium and forms 
about one-half of the dislocations. The production of these in- 
juries requires violent and severe force which twists or pushes the 
head of the bone out of its articular cavity and through the cap- 
sular ligament. The weakest point of the ligament is on the un- 
der and inner surfaces, and so also is the weakest part of the rim 
of the acetabular cavity at its lowest margin; therefore the head 
of this bone most frequently takes this route when leaving its 
usual habitat. 

SIGNS AND SYMPTOMS depend on the position in which 
the head of the bone is found. In all dislocations there is severe 
pain, inability to support any weight on the injured side and ten- 
derness on pressure; the head of the bone is absent from its usual 
position and a great nodular swelling at another part represents 
it; from one to three inches shortening of the leg with inversion 
of the foot and the head of the bone found above Xelaton's line 
occurs in the majority of dislocations; partial tloxion of the thigh 



tlA-. Jt.^ .. 



288 



INJURIES TO JOINTS OF LOWER EXTREMITY 



on to the abdomen, relaxation of the muscles of the thigh and 
loss of motion in the joint are usual. 

DIFFERENTIAL DIAGNOSIS : Extra Capsular Fractures 
which are commonest in young adults and result from violence 
directly applied over the great trochanter are sometimes mistaken 
for dislocations. With these injuries, tenderness over the great 
trochanter is extreme, crepitus is sometimes elicited, although not 
always, being absent if an impacted fracture exists. There is 




Iliac 



1 




Oiturator 



Fig. 71. — Location of head of femur in vari- 
ous forms of dislocation of the hip. (Eisen- 
drath). 



eversion of the foot and loss of motion in the joint, with an altered 
arc of rotation of the great trochanter. The use of the x-rays 
serves to make the diagnosis between a dislocation or fracture 
and should always be used if possible in this class of injuries. 

Hip Joint Disease may be existing when a slight twist or injury 
to this articulation results in a dislocation. If such a condition 
arises, an insurance company would not be liable for the disability 
which would ensue, for the reason that the dislocation while due 
to an injury would not have occurred if the disease was not previ- 



DISLOCATIONS OF THE HIP 289 

ously existing. The differential diagnosis of this disease is given 
under Sprains of this articulation. 

Congenital Dislocations of the hip when unilateral, might be al- 
leged to have resulted from an accident, but the absence of severe 
pain, tenderness and discoloration together with movement in the 




Fig. 72. — Dislocation of the right hip- 
joint showing the head of the femur rest- 
ing upon the dorsum of the ilium with 
characteristic attitude. (Scudder). 

false joint without much pain and ability to walk, stand in the 
upright position or bear weight on the so-called injured side, 
would be sufificient to prove that the dislocation was not a recent 
one. Evidence could be obtained of such an individual having 
been seen walking with a waddling gait and this would help to 
show that the dislocation was of long standing. 

COMPLICATIONS: Fractiin\^ involviiio- the neck or that 



290 



INJURIES TO JOINTS OF LOWER EXTREMITY 



part of the bone between the head and the great trochanter of the 
femur, sometimes compHcate dislocations of the hip joint and are 
diagnosed as above described. If a fracture exists in conjunction 
with a dislocation, disability is greatly prolonged and is gov- 
erned by the time required for union between the fragments. 
TOTAL DISABILITY lasts from 3 to 6 weeks in preferred 




Fracture of the neck of the femur or thigh. (Berg). 



risks suffering from any form of dislocation of this joint which is 
uncomplicated by other or more severe injuries. This period of 
disability is increased i to 3 weeks in this class, when the occupa- 
tion requires the individual to be in the erect position during 
business hours. Ordinary risks are totally disabled from 6 to 8 
weeks following this injury. 



SPRAINS OF THE KNEE JOINT 291 

PARTIAL DISABILITY of 2 to 6 weeks is sometimes pay- 
able to preferred risks when the duties of the occupation require 
considerable walking or traveling. If office duties only are per- 
formed by the claimant, i to 3 weeks are sufficient. Ordinary 
risks are not often entitled to any partial disability. 

EFFECTS: Individuals having suffered from any form of 
dislocation of the hip are not insurable for accident insurance un- 
til six to twelve months have elapsed after recovery, but Hfe or 
health insurance could be safely written from three to six months 
after the date of accident, — unless some complication existed 
with the dislocation. 

SPRAINS OF THE KNEE JOINT 

INFORMATION : Sprains of this articulation are very 
frequent and are due to direct force such as falls on the knee or 
indirect force as the result of twisting, pulling, forcible extension 
or flexion. This joint is the most compHcated one of the body and 
even slight accidents to it cause disability seemingly out of all 
proportion to the injury. Claims arising from sprains of this ar- 
ticulation are prolonged in many instances by the individual at- 
tempting to continue the occupation after the accident has oc- 
curred. 

SIGNS AND SYMPTOMS: Pain in the joint is aggravated 
on movement and especially by flexion, and gradually becomes 
worse as long as the individual attempts to use the injured knee, 
and in some cases redness of the skin follows and persists from 
twelve to twenty-four hours and then disappears. Swelling is al- 
ways present and is due to a collection of fluid inside the articu- 
lation, causing the patella to float. Tenderness on pressure is 
apparent over certain spots surrounding the knee joint, these 
places indicating the parts of the ligaments that have been torn 
and lacerated. Discoloration always ensues and is especially 
marked on the posterior surface of the joint in the popliteal space 
when the posterior or lateral ligaments have been involved. In 
severe sprains, individuals are unable to rest the weight on the 
injured leg and limited motion is evident. 

DIFFERENTIAL DIAGNOSIS: Acute Articular Rheuma- 
tism may start in this joint, the time being coincident with an in- 
jury and result in a claim in which it is alleged that a sprain is 
the cause of disabilitv- In this disease, time will alwavs niake the 



292 



INJURIES TO JOINTS OF LOWER EXTREMITY 



differential diagnosis, bnt if it is important that it be made at 
once, it can be remembered that redness, swelhng and heat are 
characteristic signs of rheumatism, and while redness may also 
exist in a sprain, it usually disappears within twenty-four hours; 
tenderness is present in both, but in rheumatism every point with- 
in four to six inches of the joint is exceedingly tender and painful, 
while in sprains tenderness exists in spots only; swelling in a joint 
affected with rheumatism is in the cellular and muscular tissues, 
while in a sprain it is usually inside the joint and the contour is 
not altered to any great extent. 




PPB 



FIG. 74.— LOCATION OF VARIOUS COLLECTIONS OF FLUID IN THE 
VICINITY OF THE KNEE-JOINT. (Eisendrath). 
A, Effusion into the knee-joint, and suprapatellar bursa: F, Femur; 
T, tibia; SPB. suprapatellar bursa; PPB, location of prepatellar bursa; 
IPB, infrapatellar bursa. B, This illustration shows the simultaneous 
collection of fluid in the prepatellar bursa (PPB), and within the knee- 
joint itself. 

Gonorrheal Arthritis can be claimed as a sprain of the knee 
joint. This disease is most frequent in men and usually occurs 
in the declining stage of a specific urethritis; therefore if a sample 
of urine is obtained, evidence of gonorrhea will be found. The 
swelling which occurs in the joint affected in this manner is gene- 
rally very extensive and is not accompanied by discoloration. If 
a claim is made on an insurance company alleging a sprain of this 
articulation and this disease exists at any stage and can be proved 
by an examination of the urine and other means, the company 
would not be liable for the disability which might ensue on ac- 
count of a gonorrheal arthritis developing in either of the knee 



SPRAINS OF THE KNEE JOINT 



293 



joints, as the policy specifically states that indemnity is not pay- 
able unless the disability is caused by an accident; and even 
though there might be a history and evidence of an accidental 
injury to the knee involved, the fact that the injury would be 
complicated by the disease would invalidate the claim. 

Tuberculous Disease of this articulation is next in frequency 
to tuberculous hip joint disease. If disability from this disease is 




Fig-. 75. — Distention of the right knee-joint witli 
fluid following a sprain. (Berg). 

claimed as due to a sprain, it can be diagnosed by the fact that in 
a sprain the leg is always in extension, while in this disease partial 
flexion is constantly present. The swelling which surrounds the 
joint becomes extensive and gives it a spindle-shaped appearance. 
Muscular spasm is marked in this disease and is not iM-osent in 
sprains; pain is severe in a sprain, while in this disease it is slight 
and the characteristic discoloration of the skin in a s]")rain follow- 
ing the effusion of blood from an injury is not present. 



294 INJURIES TO JOINTS OF LOWER EXTREMITY 

COMPLICATIONS: Partial or Complete Dislocations of the 
patella sometimes complicate an ordinary sprain of this joint, and 
if present, the length of disability would be determined in such 
cases by the complication rather than the sprain. 

Fractures involving the patella or some of the processes of 
the bones forming this articulation may occur at the time the 
sprain is sustained, but are usually not diagnosed unless the x- 
rays are employed. If a fracture of the patella exists, the length 
of disability is governed by the time required for the repair of this 
bone, either by nature or an operation. Small chips of bones 
when broken off the large bones forming the joint, prolong dis- 
abiHty and are not often diagnosed until after the length of time 
required for a sprain to recover has ended and disability is still 
present. 

TOTAL DISABILITY lasts from 5 to 10 days following 
slight sprains and contusions of the knee joint in preferred risks 
whose duties are performed at a desk. In the same class from i 
to 3 weeks are necessary when walking is required. If the sprain 
has been severe and considerable fluid has been effused into the 
joint, this disability ma}^ persist from 2 to 4 weeks in preferred 
risks when the occupation is inside and can be accomplished in a 
sitting position. The same class require from 3 to 5 weeks after 
severe sprains and the duties are outside, such as traveling sales- 
men, etc. Ordinary risks are totally disabled from 2 to 4 weeks 
from slight sprains and from 3 to 6 weeks from severe ones. 

PARTIAL DISABILITY in preferred risks whose duties are 
clerical and do not require much walking, usuall}^ lasts from i to 
2 weeks in addition to the above total. When the occupation in 
the same class of risks requires much walking, such as insurance 
solicitors, collectors, etc., partial disability ma}^ persist 2 to 4 or 6 
weeks. Ordinary risks are not often entitled to partial disability 
unless the occupation requires considerable time spent in the up- 
right position, when this disability may last from i to 3 weeks. 

EFFECTS : Individuals having suffered from an uncompli- 
cated sprain of this articulation, are insurable for all kinds of in- 
surance from one to three months after complete recovery. 

DISLOCATION OF THE KNEE 

INFORMATION: A complete dislocation between the 
lower end of the femur and the upper end of the tibia is rare, but 



DISLOCATION OF THE KNEE 295 

a partial dislocation of this joint occurs and is due to direct vio- 
lence, such as a blow on the leg or thigh above or below the joint 
or a fall on the knee. These dislocations may be forward, back- 
ward, inward or outward, the articular surface of the tibia occupy- 
ing one of these positions in relation to the articular surface of the 
lower end of the femur or a rotation of the tibia on to the femur 
may occur. Dislocations of this articulation produce longer 
periods of disability than a dislocation occurring to any other 
joint of the body. This is because the bones of this joint are held 
in apposition entirely by ligaments which are badly torn and lacer- 
ated by a dislocation; the formation of the articular surface of the 
bones does not assist in keeping them in place as in the case of the 
hip joint and some of the other articulations. 

SIGNS AND SYMPTOMS: Pain of a sickening character 
occurs after such an injury has been sustained. On examination, 
the bones are not found in the proper position, being dislocated in 
the manner as above described. There may be more or less short- 
ening of the leg, and partial flexion or extension, according to the 
form of dislocation. After the luxation has been reduced, great 
swelling of the tissues surrounding the joint occurs and is fol- 
lowed by discoloration which is very extensive; tenderness is 
present and is more marked over the ligaments that have been in- 
volved in the injury. Dislocations of this joint frequently injure 
the blood vessels and nerves of the popliteal space. Pressure on 
the popliteal artery causes obliteration of the pulse below the 
point of pressure, while injury to the nerve may cause loss of 
motion or sensation in the muscles of the leg and foot. 

DIFFERENTIAL DIAGNOSIS: Acute Articular Rlmtma- 
tism may be present in this joint and a claimant allege that the dis- 
ability is due to a dislocation. For information concerning the 
diagnosis of this disease in conjunction with the knee joint, see 
Sprains of this joint. 

Gonorrheal Rheumatism is sometimes claimed as the result of 
a dislocation, but the diagnosis is usually made without difficulty 
and is considered under sprains involving the knee joint. 

Tuberculous Disease of this joint in the second or third stage 
in isolated cases might be claimed as a dislocation. The diagnosis 
of this disease is described under the preceding article. 

COMPLICATIONS : Fractures of the Patella or some of the 
processes in connection with this articulation frequently occur in 
conjunction with a dislocation and are best diagnosed by the 



296 INJURIES TO JOINTS OF LOWER EXTREMITY 



I 



X-rays, and this means should ahvays be employed in any severe 
injury occurring to this articulation. It may be possible to diag- 
nose these small h'actures immediately after a dislocation has oc- 
curred, but swelling ensues so rapidly and becomes so extensive, 
that ascertaining if such a condition is in existence is extremely 
dif^cult by the use of the fingers alone. 

TOTAL DISABILITY in preferred risks whose occupation 
does not require the upright position, lasts from 2 to 4 weeks 
when the dislocation has been slight and much laceration of the 
ligaments is not present. In the same class when the duties are 
outside requiring constant w^alking or remaining on the feet, total 
disability lasts from 4 to 6 weeks in injuries of the same degree 
of severity. Preferred risks suffering from severe dislocations in 
which great laceration and tearing of the ligaments occurs and is 
followed by much laceration of the articular surfaces of the joint, 
require from 6 to 10 weeks of total disability. Ordinary risks suf- 
fering from partial dislocations usually demand from 4 to 6 weeks 
of this disability. When the dislocation has been complete and 
the ligaments are badly torn and lacerated, total disability of from 
8 to 12 weeks is often necessary. 

PARTIAL DISABILITY lasts from 1 to 2 or 4 weeks in 
preferred risks in addition to the above total; this time depending 
on the exact duties of the occupation. If much walking or move- 
ment in this joint is necessary, partial disability may persist for a 
longer time. Ordinary risks are generally not entitled to any par- 
tial disability, as the occupation is not resumed until complete 
recovery ensues. 

EFFECTS : An individual having suffered from a partial or 
complete dislocation of this joint is an impaired risk for accident 
insurance until at least two to three years have passed and during 
which time no signs or symptoms of the injury show themselves. 
Life or health insurance can be safely written from three to six 
months after the date of accident, if the injury has' been uncom- 
plicated and recovery ensues within a reasonable time. 

DISLOCATION OF THE PATELLA 

INFORMATION: Dislocations of the patella occur to 
either side of the knee joint; more frequently the bone is displaced 
externally, either partially or completely. These displacements 
are the result of external violence in which a fall is sustained and 



DISLOCATION OF THE PATELLA 



297 




the weight of the body falls on the patella or the bone is violently 
struck by -some obstacle; sometimes the cause is muscular action. 
Reduction of this injury often occurs spontaneously and this is 
especially the case if there is a history of previous displacements. 
Rotation of the patella sometimes occurs in a displacement and 
comphcates the injury, causing much trouble in reducing the de- 
formity. 

SIGNS AND SYMPTOMS: Following a displacement of 
this bone, the leg is partly flexed upon the 
thigh and the patella is found in an abnormal 
position; a depression, or fiat surface occupy- 
ing the place where it belongs. There is pain, 
with tenderness over the lateral ligaments op- 
posite to the side on which the displacement 
occurs; swelling with broadening of the knee 
supervenes and later is followed by discolora- 
tion. If much effusion has existed in the 
joint, synovitis may develop, when grating 
between the articular surface is elicited on 
movement. 

COMPLICATIONS: Fractures of the 
patella in which a part of the bone has been 
chapped ofif, not infrequently occur in a dis- 
placement of this large sesamoid bone and 
are not often diagnosed unless the x-rays are 
used. 

Synovitis is usual after a partial or com- 
plete displacement of the patella and is ac- 
companied by fluid inside the articulation; 
this causes the patella to be raised up or 
''float." Pain is worse on movement and 
at night and motion causes grating which is 
easily felt; redness of the skin does not occur, 
but sometimes local heat is present lasting 
for twenty-four to thirty-six hours. 

TOTAL DISABILITY lasts from 2 to 3 weeks in preferred 
risks whose occupation requires constant standing or consider- 
able walking. In the same class, from i to 2 weeks only are re- 
quired when the duties are at a desk and the upright ]H\^ition is 
not necessary. Ordinary risks demand from 2 to 4 weeks of this 




FIG. 76.— OIJ T W AR I> 
DISLOCATION OF 
PATELLA. (Fowler). 



298 INJURIES TO JOINTS OF LOWER EXTREMITY 

disability following a complete or partial displacement of the pa- 
tella. 

PARTIAL DISABILITY of i to 3 weeks is often payable 
to preferred risks w^hose duties are mainly outside, such as bank 
runners, soHcitors, etc. In the same class when the duties are 
ofBce and supervising, i to 2 weeks are usually sufficient. Ordi- 
nary risks seldom require any partial disability. 

EFFECTS : Displacements of the patella are very prone to 
recur at the slightest act of over-exertion or accidental injury, 
and an individual with a history of having suffered from such an 
accident is not insurable for an accident poHcy until at least a 
year or more has elapsed without any signs or symptoms referable 
to the displacement. Accident insurance companies sometimes 
accept these risks by placing a waiver on the policy eliminating 
indemnity for any disability that may be due directly or indirectly 
to the affected knee. Life or health insurance can be written on 
such a risk as soon as recovery ensues. 

DISLOCATION OF THE SEMI-LUNAR CARTILAGES 

INFORMATION: A dislocation of the internal or external 
semi-lunar cartilage of the knee occurs and is due to indirect 
force and is most commonly produced when the joint is flexed 
and a sudden twisting of the foot or leg tears one of these liga- 
ments from its attachments. The internal Hgament is the one 
m^ost often dislocated. 

SIGNS AND SYMPTOMS : As the dislocation occurs when 
the leg is flexed, it immediately produces a locking of the joint 
which remains in this position. There is sudden, sharp pain with 
inability to use the leg of the injured side; swelHng and sometimes 
the dislocated cartilages can be felt by the fingers. 

TOTAL DISABILITY in preferred risks lasts from 2 to 3 
weeks when the duties of the occupation require the upright posi- 
tion. In the same class from i to 2 weeks are usually ample when 
the work is inside and little walking is necessary. Ordinary risks 
demand from 2 to 4 weeks of this disabiUty. 

PARTIAL DISABILITY of from i to 2 weeks is payable to 
preferred risks after such an injury has been sustained. Ordinary 
risks are not often entitled to this form of disability. 

EFFECTS: When a dislocation of either of the cartilages 
has occurred, a recurrence of the same is frequent; therefore such 



SPRAINS OF THE ANKLE JOINT 299 

an individual is not insurable for an accident policy, unless the 
policy contains a waiver eliminating indemnity for disability re- 
sulting directly or indirectly from the impaired knee or an opera- 
tion has been performed and the cartilage removed or sutured to 
its attachments. Life or health insurance can generally be 
granted from one to two months after the date of accident. 

SPRAINS OF THE ANKLE JOINT 

INFORMATION : Sprains of the ankle joint occur more 
frequently than do sprains to any other joint of the body. All de- 
grees of severity are seen in this injury, from a slight sprain which 
tears a small part of one of the ligaments, to a severe one where 
several Hgaments are badly torn and lacerated. These injuries 
are usually due to turning of the foot for some reason or other and 
the weight of the body coming down on the extremity in that posi- 
tion, when a tear of the ligament on the convex surface of the 
curve occurs. Other causes which produce this injury are twist- 
ing of the foot, ever extension and extreme flexion. 

SIGNS AND SYMPTOMS : Immediately after the accident 
occurs, there is pain in the joint which is increased on movement, 
swelling in a short time becomes extensive and tenderness exists 
over the ligaments which have been torn. Several hours after a 
severe sprain of this articulation, the individual is unable to place 
any weight on the foot of the injured side and discoloration begins 
to show and becomes very marked in twelve to thirty-six hours. 

DIFFERENTIAL DIAGNOSIS: Fractures involving the 
internal or external malleolus sometimes occur in conjunction 
with a sprain and are best diagnosed by the x-rays. If such a 
means of diagnosis is not possible, crepitus can sometimes be 
elicited between the ends of the fractured bone. If the fibula is 
broken at any part of its course, by making pressure with each 
hand over the extremities of the bone and having some one press 
along its shaft, the spring of the bone can be felt if no fracture 
exists. If the tip of the internal malleolus is broken oft', a com- 
parison of the two sides will usually show a dift'erence and a 
slight depression will be found at the point of fracture. 

Tubercidons Disease of this joint usually begins as a chronic 
synovitis and no history of an injury is present. The foot is held 
in extension and this is not the position assumed after a sprain. 
The swelling which surrounds the joint in this disease is globular 



T— W 



300 INJURIES TO JOINTS OF LOWER EXTREMITY 

in form; whereas a swelling due to a sprain — while it may involve 
the whole joint — is pronounced on the side in which the greatest 
tear of the ligament occurs. The skin in this disease is either pale 
or of a deep reddish hue, while following a sprain, discoloration 
due to effusion of blood under the skin is present, and this dis- 
coloration goes through the different stages, finally disappearing 
under a greenish-yellow color; marked atrophy of the calf is pres- 
ent in tuberculous disease of this joint and is not seen in a sprain. 

Acute Articular Rhcuinatisin may commence in this articula- 
tion and the time be coincident with an injury. This disease is 
accompanied by elevation of the body temperature which is not 
present in sprains; swelling of the joint which involves all the tis- 
sues surrounding it, with heat and redness persisting during the 
time the articulation is involved, while the swelling in a sprain is 
usually more marked on the side indicating the most severe tear 
of the ligament; heat and redness may be present, but do not last 
longer than twelve to twenty-four hours. Pain is severe in an 
attack of arthritis and tenderness exists over all parts of the joint, 
while in a sprain tenderness is more marked over the torn liga- 
ments. 

COMPLICATIONS: Fractures of the internal malleolus fre- 
quently complicate severe sprains of this articulation and are not 
usually diagnosed unless a skiagraph is made. When the tip of 
the internal malleolus is torn off, the injury is usually designated 
— when known — as a sprain or chip-fracture. Fractures of the 
lower end of the fibula and the internal malleolus of the tibia — 
known as Pott's fracture — sometimes complicate a severe sprain 
of the ankle, when the disability is prolonged and the time is gov- 
erned by the more serious injury. 

TOTAL DISABILITY in preferred risks lasts from 2 to 7 
days when the ankle has been slightly sprained and the occupation 
requires a sitting position. In the same class and with a sprain 
of the same degree of severity, from i to 2 weeks are necessary 
when the duties require much walking. Severe sprains in the 
same class of risks require from 2 to 3 weeks when the individual 
works at a desk. If the duties demand the upright position, from 
2 to 4 weeks are necessary after severe sprains in preferred risks. 
Ordinary risks require from i to 4 weeks of this disability accord- 
ing to the degree of severity and the exact duties of the occupa- 
tion. 

PARTIAL DISABILITY is payable to preferred risks in ad- 



DISLOCATION OF THE ANKLE JOINT 301 

dition to total and from i to 4 weeks are usually demanded when 
the occupation requires considerable walking. In the same class 
and when the duties are inside and at a desk, this form of dis- 
ability does not often require more than from i to 2 weeks. Or- 
dinary risks seldom ask an}^ partial disability, unless the occupa- 
tion requires considerable walking, and then from i to 2 weeks 
may be necessary. 

EFFECTS : Individuals having suffered from a sprain of this 
joint are insurable for all kinds of insurance from one to two 
months after complete recovery; unless there is a history of re- 
peated sprains to the same articulation, when an accident policy 
should not be issued without a waiver eliminating indemnity for 
disability due to an accident caused by weakness of this joint. 
Life or health insurance can be safely written as soon as recovery 
ensues. 

DISLOCATION OF THE ANKLE JOINT. 

INFORMATION: Dislocations of the ankle joint or dis- 
placements of the superior articular surface of the astragalus from 
the articular surface of the lower end of the tibia and fibula occur 
either forward, backward, inward, outward or upward. A dislo- 
cation in this situation is almost always complicated with either 
a Pott's or Dupuytren's fracture. This accident may follow from 
indirect force, such as a fall from a height and landing on the feet 
and the foot is either pushed forw^ards or backw^ards or by sud- 
den, violent twisting which results in lateral dislocations. 

SIGNS AND SYMPTOMS: Deformity is always marked 
when this injury occurs, and if the dislocation is forward, the foot 
is lenghtened and the heel almost obliterated. When the disloca- 
tion is backward, the foot is shortened and the heel becomes more 
prominent. Lateral dislocations show the foot twisted and fixed 
in an unnatural position. There is severe pain, much swelling, fol- 
lowed by discoloration and tenderness over the whole joint. 

DIFFERENTIAL DIAGNOSIS: Acute Articular Rhcuuui- 
tisin involving the ankle joint might be claimed to have started 
with a dislocation, but as a dislocation almost always requires re- 
duction by a surgeon, a history of this could be obtained and veri- 
fied. Rheumatism would not conuuence in the same manner and 
would usually be preceded by exposure to cold or dam]Mioss. As 
this disease almost invariablv affects more than one joint, the 



302 INJURIES TO JOINTS OF LOWER EXTREMITY 

diagnosis can be easily made by availing until the joint recovers 
and another one becomes affected. Should an attack of rheuma- 
tism commence or follow a dislocation, the affected joint would 
probably be well of the disease before the disability from the ac- 
cident would end, and if the individual was covered by a general 
health policy, indemnity would be payable whether disability was 
due to an accident or disease. If an accident policy only was car- 
ried, insurance companies would usually allow a fair time for the 
duration of disability that would follow a dislocation, irrespective 
of the fact that the policy provides ''indemnity for disability un- 
complicated by disease." 

Tiihcrciilons Arthritis of the ankle joint occurring in the early 
stages may sometimes be mistaken for a dislocation. In this dis- 




Fig. 77. — Inward and outward dislocation of the ankle-joint, with fracture 
tibia and fiibula, (Hoffa). 

ease, however, the swelHng is globular in shape and is confined to 
the immediate vicinity of the joint; while swelling following a dis- 
location would extend up the leg and down into the foot and 
would soon be followed by discoloration characteristic of effusion 
of blood under the skin. The discoloration present in this disease 
is of a purplish hue and this persists for weeks and does not end 
l)y resolution, but results in caseation and formation of sinuses. 

COMPLICATIONS : Potfs Fracture almost invariably com- 
plicates a dislocation of the ankle, and the length of disability is 
therefore governed by the time required for union between the 
ends of the fractured bone. 

Dupuytren's Fracture complicates severe outward dislocations 
of this joint, and disability is prolonged until union is complete 
between the fractured ends of the bone. 



SPRAINS OF THE FOOT AND TOES 303 

TOTAL DISABILITY in dislocations of this joint which 
are uncompHcated by fractures and the Hgaments are not badly 
torn, lasts from i to 3 weeks in preferred risks whose duties do 
not require much walking. In the same class and under the same 
conditions when the duties require much time spent walking or 
in the upright position, total disabihty lasts from 2 to 4 weeks. 
Preferred risks suffering from severe dislocations in which the 
ligaments are badly torn and lacerated and a probable fracture 
exists as a complication, require from 3 to 6 weeks of this disabil- 
ity. Ordinary risks suffering from sHght dislocations require 
from 2 to 4 weeks of total disability and from 4 to 8 weeks when 
the dislocation has been severe. 

PARTIAL DISABILITY lasts from i to 3 weeks in pre- 
ferred risks whose duties are mainly clerical, and from 2 to 6 
weeks when constant walking or standing is required. Ordinary 
risks are seldom entitled to any partial disability, they being able 
to resume all the duties of the occupation when they return to 
work. 

EFFECTS : Individuals having suffered from a dislocation 
of this joint are not insurable for an accident poHcy until at least 
one year has passed after the date of accident, unless a waiver is 
placed on the policy eliminating indemnity for disabiHty as the re- 
sult of the weakened ankle. Life or health insurance can be safely 
written from one to two months after total disability ends. 

SPRAINS OF THE FOOT AND TOES 

INFORMATION: Sprains of the foot often occur in con- 
junction with a sprain of the ankle joint. When a sprain involving 
one of the articulations between the bones of the foot exists, it 
is generally the result of a fall, the body alighting on the feet and 
the ligaments which hold the bones forming the arch of the foot 
together are torn. Sprains of the toes are usually trivial injuries 
and occur from various causes; the individual most often being- 
barefooted when these injuries are sustained. A sudden twisting 
of the foot or a weight falling on it may produce sprains of these 
joints in addition to the contusion of the foot which is also pres- 
ent. 

SIGNS AND SYMPTOMS: Pain is always complained of 
and this is made worse when the weight of the body is put on the 
injured foot; tenderness on pressure is present in spots and swell- 
ing soon appears, to be followed later by discoloration. 



304 INJURIES TO JOINTS OF LOWER EXTREMITY 

COMPLICATIONS: Fractures or Dislocations of the tarsal 
or meta-tarsal bones may complicate a sprain and not be diag- 
nosed unless a radiograph is made. If either of these compHca- 
tions occur, disabiHty is prolonged and the time required for re- 
covery is described under the most severe injury. 

TOTAL DISABILITY in preferred risks whose duties are 
performed at a desk, require from 3 to 7 days after sHght sprains 
of the foot have been sustained. In the same class and the duties 
are outside, from i to 2 weeks are necessary. Preferred risks 
whose duties require the upright position are totally disabled from 
2 to 3 weeks following a severe sprain of the foot. AMien the oc- 
cupation requires much walking, total disability lasts from 3 to 
4 weeks in the same class and after a sprain involving several 
joints. Ordinar}' risks are totally disabled from i to 2 weeks for 
slight sprains and from 2 to 4 weeks for severe ones of the joints 
of the foot. Sprains involving one or more of the toes in all 
classes of risks sometimes require from i to 5 days of total dis- 
ability. 

PARTIAL DISABILITY is necessary in preferred risks 
whose occupation does not require much w^alking and lasts from 

1 to 2 weeks. In the same class when the individual is in the up- 
right position during business hours, this disabiHty may last from 

2 to 3 weeks. Ordinary risks do not often demand partial dis- 
ability and when payable from i to 2 weeks are usually sufficient. 
Partial disability is not deserved following sprains of the toes in 
any class of risks. 

EFFECTS : Individuals having suffered from sprains involv- 
ing the foot or toes, are insurable for all kinds of insurance from 
two to four months after the date of accident, provided recovery 
ensues within a reasonable time. 

DISLOCATIONS OF THE BONES OF THE FOOT 

AND TOES 

INFORMATION : Dislocations between the tarsal or meta- 
tarsal bones of the foot or the phalanges of the toes may occur. 
The most common dislocation involving the bones of the foot is a 
displacement of the astragalus, and this injury results from a fall 
when the individual alights on the foot or by sudden, violent 
twisting. Dislocations involving the meta-tarsal bones them- 
selves and the bones with which thev articulate, occur in various 



DISLOCATIONS OF BONES OF FOOT AND TOES 305 

directions. The joints of the toes are sometimes dislocated and 
these accidents generally happen when the individual is bare- 
footed and unexpectedly strikes the toes against a hard object. 

SIGNS AND SYMPTOMS: Deformity of more or less 
marked degree is present after a dislocation involving any of the 
joints of the foot or toes. This is followed by pain which is ag- 
gravated by resting any weight of the body on the injured foot 
and swelling and discoloration which sometimes extend up the 
leg. Tenderness over the bone dislocated is elicited on pressure 
and the individual is unable to rest any weight on the foot. Dis- 
locations of the joints of the toes produce localized pain, sweUing, 
deformity, discoloration and tenderness. 

COMPLICATIONS: Fractures often accompany a disloca- 
tion of some of the bones of the foot or toes and are usually easily 
diagnosed. If a fracture involving the tarsal bones is suspicioned 
and cannot be ascertained by digital examination, the use of the 
x-rays will serve to make the diagnosis clear. 

TOTAL DISABILITY in preferred risks suffering from a 
dislocation involving the tarsus and meta-tarsus, lasts from 2 to 
4 weeks when the occupation requires much walking. The same 
class suffering from a similar dislocation, require from 2 to 3 
weeks when the duties are performed in a sitting position. Ordi- 
nary risks require from 3 to 6 weeks when a dislocation of these 
bones occurs. A dislocation involving the joints of one or more 
toes produces from 3 to 10 days of total disability in all classes of 
risks; the length of time depending on the exact duties of the oc- 
cupation. 

PARTIAL DISABILITY lasts from 2 to 6 weeks following 
a dislocation involving the bones of the foot in preferred risks 
whose occupation requires constant walking or standing. In the 
same class, from i to 3 weeks are sufficient when the duties are 
performed in a sitting position. Ordinary risks seldom demand 
any partial disability. Partial disability of i to 2 weeks is some- 
times necessary in all classes of risks after severe dislocations in- 
volving the joints of the toes; this is especially true if the great 
toe is the one injured. 

EFFECTS: When a dislocation between the joints of the 
foot occurs, it usually results in more or less stift'ening in the ar- 
ticulation involved, but this is not sufficient to prevent an indi- 
vidual from buying any kind of insurance from one to three 
months after the date of accident. 
20 



306 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 



PART III 

FRACTURES AND AMPUTATIONS INVOLVING THE PELVIS 
AND LOWER EXTREMITY 

FRACTURES OF THE PELVIS 

INFORMATION : Fractures of the pelvis may occur to one 
of the bones forming it or to some of the processes connected 
therewith, and these fractures are usuahy due to direct violent 
force, such as follows when the body is run over by a heavy ve- 
hicle or caught and crushed in an elevator or railroad accident. 
These fractures may be compound internally, when some of the 
tissues or organs of the abdominal cavity are injured or the frac- 
tured bones may protrude through the skin, producing the usual 
form of compound fracture. 

SIGNS AND SYMPTOMS: Following an injury of this 
kind, there is always a history and evidence of violent force ap- 
plied to this part of the body, and these injuries are usually ag- 
gravated by injuries to other parts. Severe pain is complained of 
over the point of fracture, and this is made worse by pressing the 
pelvis together, movement of the body, coughing, sneezing or 
straining at stool. The individual is unable to stand on the feet 
and when lying down cannot raise the lower extremities. There 
is swelling and discoloration and crepitus can usually be obtained 
by bimanual examination with the fingers of one hand in the 
vagina or rectum. 

COMPLICATIONS: Compound Fractures of the Pelvis in 
which the bladder or urethra has been injured are indicated by 
pain over this region and a constant desire to urinate, hematuria 
and extravasation of urine into the connective tissue. Such a 
complication may or may not prolong disability. If only a slight 
tear occurs and an operation is not necessary for its repair, dis- 
ability is not prolonged thereby. A severe rupture of the bladder 
or urethra necessitating an operation increases disability four to 
six weeks. 

Injuries to the Uterus and Vagina may be present when a frac- 
ture of the pelvis is sustained by a female. These injuries, how- 



FRACTURES OF THE PELVIS 307 

ever, are usually entirely recovered before disability necessary for 
the fractured pelvis is ended. 

RiipHirc of the Rectum complicates fractures of the pelvis and 
is usually due to a small spicula of bone entering this part of the 
gut and tearing or lacerating it. These lacerations seldom re- 
quire an operation for repair, and disability is therefore not pro- 
longed by them. 

Septic Peritonitis may develop as the result of an intestinal 




Fig. 78. — Typical locations of lines of fracture in fractures of 
the pelvis. (Eisendrath). 

injury, when the fracture is compound internally, and perhaps ex- 
ternally. Such cases are almost invariably fatal within a short 
time. 

TOTAL DISABILITY following fractures of the pelvis de- 
pends on the cause of the injury, the location, extent, severity 
and complications. Uncomplicated fractures involving some of 
the processes or rim of the pelvis require from (> to to weeks of 
total disability in all classes of risks. If the fracture involves the 
innominate bones and is uncomplicated, total disability lasts from 



308 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

8 to 12 weeks in preferred risks. Ordinar}^ risks require from lo 
to 1 6 weeks of this disability for such an injury. When the frac- 
ture is compHcated by injury to the viscera, total disability may 
be prolonged, and if so, the length of time is described under the 
complication. 

PARTIAL DISABILITY of from 3 to 6 weeks is payable 
to preferred risks following a fracture of this character. Ordi- 
nary risks are not often entitled to any partial disability. 

EFFECTS : Individuals suffering from uncomplicated frac- 
tures of the pelvis that have united without involving any of the 
viscera in the callus, are not insurable for any kind of insurance 
until at least one year after the date of accident. If the injury has 
been comxplicated, an insurance company would hardly issue any 
kind of a policy until after a most rigid medical examination, and 
if the complication has been a rupture of the urethra or bladder, 
the majority of companies would not consider the risk insurable 
for any kind of a policy. 

FRACTURE OF THE FEMUR 

INFORMATION: Fractures of the femur are divided into 
three divisions, those affecting the upper extremity, the shaft and 
the lower extremity, and these fractures may be due to direct or 
indirect force; the location of the injury usually determining the 
manner in which the violence was received. Intracapsular frac- 
tures generally occur in the aged and are especially frequent in 
women and almost always result from indirect violence, such as 
a twist of the leg during a fall. Extracapsular fractures of the 
neck and in rare instances those of the great trochanter are usually 
due to direct force which is applied over the point of injury; while 
m.uscular action is sometimes the cause of fractures of the shaft. 
Fractures of the lower extremit}^ or between the condyles are 
most often due to indirect force, such as a fall from a height when 
the tibia is forcibly driven against the lower extremity of the 
femur and a split or fracture results. 

SIGNS AND SYMPTOMS depend on the location of the in- 
jury. Fractures involving the upper extremity when not im- 
pacted, show shortening of the leg of one to three inches, eversion 
of the foot, absolute inability to stand on or move the injured 
leg, partial flexion of the leg and thigh, an altered arc of rotation 
of the great trochanter and its ascent above Nelaton's line, to- 



FRACTURE OP THE FEMUR 



309 



gether with pain which is referred to the joint and is increased 
on movement, extreme tenderness in this locaHty, swelhng and 
discoloration. Crepitus is sometimes elicited between the frac- 
tured ends of the bone, but is not constant. Fractures of the shaft 
produce shortening of the leg of two to three inches, unnatural 
mobility at the point of injury, great deformity, the ends of the 



I 




Fig". 79. — Fracture uf the left femur 
upper third. Dotted lines show posi- 
tion the leg may assume after a frac- 
ture occurs. (Scudder). 



fractured bone being plainly felt in unnatural positions, eversion 
of the foot, absolute loss of motion and inability to place any 
weight on the injured leg. There is severe pain at the point of 
fracture, with crepitation when the fractured ends are rubbed to- 
gether, great swelling and discoloration. Fractures involving the 
condyles show some deformity, the knee usually being broadened, 



310 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

crepitation is present, pain over the fracture and much swelling- 
with discoloration exists. The use of the x-rays is always de- 
sirable in fractures involving any part of this bone and should be 
employed in making the diagnosis and also after reduction has 
been performed. 

DIFFERENTIAL DIAGNOSIS: Dislocations of the head 
of the femur may sometimes be mistaken for intra or extracap- 
sular fractures of this joint and are best diagnosed by use of the 
x-rays. In dislocations, inversion of the foot is the usual position 
assumed, the head of the bone by palpation is found in its un- 
natural position and a depression exists over the place it formerly 
occupied; there is no crepitus and no false joint as occurs after a 
fracture, but rigidity where a joint normally exists. Dislocations 
into the thyroid notch show lengthening of the leg and sometimes 
eversion of the foot. 

COMPLICATIONS: Dislocations of the head of the femur 
sometimes complicate fractures involving the upper extremity 
and are best diagnosed by use of the x-ray, which should be used 
in every case when possible. 

Fractures involving the lower end of the femur are usually 
sustained in conjunction with an injury to the knee joint, when 
an effusion takes place and more or less stiffening results. Injury 
to this joint, however, does not prolong disability, as the inflam- 
mation inside the articulation has usually entirely subsided by the 
time union between the fractured ends of the bone is complete. 
If the fracture has produced much injury to the joint, considerable 
stiffening and loss of motion results, but this may be somewhat 
reduced by proper and early massage. 

TOTAL DISABILITY lasts from lo to i6 weeks in pre- 
ferred risks who have suffered from a fracture involving the "shaft 
or lower extremity of the bone and the occupation requires much 
walking. In the same class and when the fracture exists in a simi- 
lar location, total disability lasts from 8 to 12 weeks when the 
duties of the occupation can be performed in a sitting position. 
Ordinary risks require from 12 to 16 weeks of this disability fol- 
lowing a fracture involving any part of this bone. Compound 
fractures of this bone prolong disability 2 to 4 or 6 weeks. Un- 
united fractures of the shaft are usually not diagnosed until from 
4 to 6 weeks after the accident, when an operation is frequently 
necessary and total disability in all classes of risks lasts from 6 
to 10 weeks after .the date of operation. Fractures involving the 






AMPUTATION OP THE THIGH 311 

upper extremity when occurring in aged individuals, produce total 
disability of from 3 to 6 months and sometimes longer, — if the 
accident does not result in death within from 3 to 6 weeks. 

PARTIAL DISABILITY of from i to 2 months is payable 
to preferred risks when the occupation does not require the up- 
right position. In the same class, from i to 3 months are neces- 
sary if the duties are outside, such as collectors, solicitors, etc. 
Ordinary risks do not often demand partial disability following a 
fracture of this character, but in some cases it is necessary and 
from I to 2 months are usually required. 

EFFECTS : Individuals recovering from a fracture involv- 
ing the shaft or upper extremity of this bone usually have some 
shortening of the leg. If the fracture is in the lower extremity, 
shortening does not often result, but more or less impairment 
of motion may be present, on account of the knee joint having 
been involved in the injury. Accident insurance should not be 
granted to a person who has suffered from this fracture until at 
least nine to twelve months have elapsed after the date of injury, 
and not even then unless complete recovery has ensued and no 
impairment of motion is present. Life or health insurance may be 
issued to such an individual from six to eight months after the 
date of accident, provided recovery has progressed satisfactorily. 

AMPUTATION OF THE THIGH 

INFORMATION: Amputations through any part of the 
femur as the result of accidental injuries, are not often performed 
except after severe accidents in which the bone is badly broken 
and the tissue lacerated. These injuries are usually the result of 
some heavy body passing over the thighs, such as railroad trains, 
trolley cars, etc. One or both lower extremities may be ampu- 
tated through the shaft of the femur or at the hip joint, and in the 
latter case the injury is generally so severe and shock so pro- 
nounced that death almost always follows within a short, time. In- 
surance companies pay a certain figure for accidental injuries re- 
sulting in the amputation of one or both legs at or above the 
ankle joint, provided the operation is performed within ninety 
days. Some companies pay in addition to this weekly indemnity 
for the time disability lasts. Should an accidental injury result in 
an amputation of one or both legs through the femur and death 
result within ninety days, the company would be liable for the 
full amount of the policy. 



312 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

SIGNS AND SYMPTOMS : Evidence is apparent of a badly 
lacerated leg; in addition there is usually unconsciousness if the 
individual is seen immediately after the accident, with extensive 
hemorrhage, pain and severe shock. These injuries are almost 
invariably accompanied by injuries to other parts of the body; in 
some cases they may be as severe as the one requiring the am- 
putation, such as a fractured skull and fractures involving other 
bones. 

COMPLICATIONS : Fractures to other bones of the body 
are usually seen in conjunction with these severe injuries, but un- 
less death ensues from some cause, the disability is not often pro- 
longed beyond the time required for recovery following such an 
amputation. 

Pleurisy and Pneiunonia following these injuries are some- 
times due to a fractured rib, or the result of exposure. If death 
does not ensue from the severe injury, the complication has gene- 
rally disappeared before recovery is complete. Should death oc- 
cur within ninety days from pneumonia which was caused by the 
end of a fractured rib, it is probable that an insurance company 
vvould be held liable for the full amount of an accident policy, but 
if death followed pneumonia which was due to exposure after such 
an injury had been sustained, it is questionable if an accident in- 
surance company would pay a death indemnity from such a cause. 

TOTAL DISABILITY lasts from i to 3 or 7 days when a 
fatal termination occurs. If the individual recovers, from 12 to 
16 weeks are necessary of this disability in all classes of risks fol- 
lowing an amputation through the hip joint. If the operation re- 
m.oves the leg through some part of the shaft of the femur, this 
disability lasts from 8 to 12 weeks in all classes of risks. Infection 
is usually present in all these cases and is considered in the above 
time. Accidents requiring an amputation of both legs through 
the shaft of the bones followed by recovery — which is rarely the 
case — require from 12 to t6 weeks of total disability. 

PARTIAL DISABILITY commences as soon as total dis- 
abiHty is ended and persists during the life of the individual, but 
partial indemnity is never payable, for the reason that the poHcy 
provides a specific sum for these amputations and the insurance 
company has usually paid the claim long before partial disability 
begins. 

EFFECTS : Individuals having suffered the loss of one or 
both legs are impaired risks and are not insurable for accident 



FRACTURES OF THE PATELLA 313 

insurance. If only one leg has been lost, insurance companies will 
generally issue life and health policies two to three years after 
the date of accident, provided a good stump is the result of the 
amputation and no evidence of any disease or trouble exists. 

FRACTURES OF THE PATELLA 

INFOR]\L\TION : Fractures of the patella are of frequent 
occurrence and are more common between the ages of twenty and 
fifty years. These injuries are usually due to muscular action and 
sometimes by direct, violent force when a fall is sustained on the 
knee. When a fracture of this bone is due to muscular action and 
is caused b}^ a slip, an accident policy would cover the disability, 
but if the individual was trying to raise a weight with the leg and 
fractured the patella in this manner, it would be due to a volun- 
tary act and would not be covered by an accident policy. 




Fig. 80. — Fracture of patella with great separation of fragments. Condyles of the 
femur are prominent between the fragments. A, The lower fragment; B, the 
condyles of the femur; C, the upper fragment. (Scudder). 

SIGNS AND SYMPTOMS: Immediately after the fracture 
occurs, there is severe pain, followed by enormous swelling of the 
joint which is due to effusion of fluid and blood inside the articula- 
tion and later discoloration. When the fracture is complete, there 
is evidence of a part of the bone, being drawn upward and another 
part downward, these two fragments being plainly felt, and be- 
tween them where the patella normally belongs, a hollow exists 
and is easily distinguished by palpation. Loss of power of exten- 
sion of the leg on the injured side is present. 



314 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

DIFFERENTIAL DIAGNOSIS: Lateral Displacements of 
the Patella might be diagnosed as a fracture of this bone when the 
swelling is so great that an examination is not satisfactory. As 
soon as this swelling recedes, however, the patella is found intact 
at either side of the joint and can then be reduced; while if a frac- 
ture exists, it is rare that either of the fragments are displaced lat- 
erally, and when they are partly brought together, the quadriceps 
extensors pull the upper fragment away from its proper position 
and there is a separation between the two. 

COMPLICATIONS: Synovitis of the knee joint invariably 
follows a fracture of this bone and is due to the effusion of blood 
into the articulation. This inflammation is generally sufificiently 
recovered by the time the fractured ends of the bones are united 
together by fibrous union, that disability is not prolonged by the 
complication. 

TOTAL DISABILITY lasts from 3 to 6 weeks in preferred 
risks when the occupation requires a sitting position and a small 
oblique fracture exists. In the same class and with the same 
duties after a transverse fracture of the patella is sustained, this 
disabihty lasts from 4 to 6 or 8 weeks. Preferred risks whose 
duties require the upright position or much walking usually de- 
mand from 6 to 10 weeks of total disabihty following a fracture 
of any kind involving this bone. Ordinary risks are generally 
totally disabled from 8 to 12 weeks. A compound fracture of this 
bone when produced accidentally may prolong disability 2 to 4 or 
6 weeks in all classes of risks. If an ^operation is performed for 
weiring the fragments together, total disabilit}' lasts from 3 to 6 
weeks in all classes after the date of operation. 

PARTIAL DISABILITY of from 4 to 8 weeks is required 
by preferred risks whose duties are inside and little walking is 
necessary. In the same class when the accident occurs among 
individuals such as collectors, solicitors, store clerks, etc., partial 
disability lasts from i to 3 or 4 months. Ordinary risks do not 
often ask for partial disability, but this form is sometimes neces- 
sary and from i to 3 months may be demanded. 

EFFECTS: The two fragments of this bone are generally 
united by fibrous union and in such cases this fibrous tissue in- 
variably stretches, thus producing an impaired risk for accident 
insurance. If the fragments of the bone have been united by 
bony tissue or wired together, union is perfect and the individual 
is insurable for all kinds of insurance from three to six months 



FRACTURES OF THE TIBIA AND FIBULA 



315 



after complete recovery, provided sufficient motion for the pre- 
vention of accidents exists in the injured joint. 

FRACTURES OF THE TIBIA AND FIBULA 

INFORMATION : Fractures of these two bones may exist 
in the upper, middle or lower third and are caused by direct or 
indirect violence and muscular action. Fractures involving the 
lower extremity of either bone are usually seen in conjunction 
with an injury to the ankle joint and are described as Fractures of 
the Ankle Joint. Fractures of the tibia most commonly involve 
the shaft and almost alwavs are due to direct force; the fracture 





Fig-. 81. — Fracture of 
the tibial shaft. (Scud- 
der). 



Fig-. 82. — Fracture 
of tibial shaft. (Scud- 
der). 




Fig. 83. — Frac- 
ture of tibial shaft. 
(Scudder). 



usually being transverse in the upper part of the shaft of the bone 
and oblique when the lower section is involved. 

SIGNS AND SYMPTOMS depend on the bone fractured. 
Transverse fractures of the tibia produce no deformity and the in- 
dividual is often able to walk when the fibula remains intact. In 
■oblique fractures there is slight deformity which is usually easily 
corrected. Crepitus exists in both forms when the ends of the 
bone are moved one upon the other; pain is present with swelling 
and discoloration. Fractures involving the fibula produce little 
apparent deformity; crepitus can sometimes be elicited, pain is 
present, swelling and discoloration follow and when pressure is 
made on the two extremities of the bone and also on its centre, 
evidence that these two ends are not connected is apparent. Frac- 
tures of this bone do not prevent an individual from walking. 



316 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

Fractures involving the upper end of the fibula or the tuberosities 
of the tibia, produce little deformity, and if the line of fracture is 
longitudinal between the tuberosities of the tibia, the individual is 
unable to put any weight on the injured leg. The x-rays afford 
the best means of diagnosis for fractures involving the upper ex- 
tremity of this bone and should always be employed if possible. 

COMPLICATIONS : Dislocation of the head of the fibula 
from the articular surface of the tibia is sometimes present in a 
fracture involving the shaft of this bone and may cause a localized 
synovitis in this joint, but it must be remembered that this articu- 
lation does not communicate with the knee joint and therefore 
this latter joint is not involved in a dislocation of the tibio-fibula 





Fig. 84. — Fracture 
of the tibia and 
fibula. (Scudder). 



Fig. 85. — Fracture of 
the tibia and fibula. 
(Scudder). 



articulation and disability is not prolonged when this complica- 
tion exists. 

Longitudinal Fractures between the tuberosities of the tibia re- 
sult in a synovitis of the knee joint, but unless the injury has been 
much aggravated after it occurs by the individual trying to walk 
or persisting in attempting to remain on his feet, disability is not 
prolonged by the complication, as the inflammation is usually not 
extensive. 

TOTAL DISABILITY lasts from 6 to 8 weeks in preferred 
risks when the occupation requires considerable walking and the 
shaft of the tibia has been fractured. In the same class suffering 
from a similar fracture, when the duties of the occupation are per- 
formed at a desk, total disability lasts from 3 to 6 weeks. These 
individuals in many cases get to their place of business shortly 



AMPUTATION OP THE LEG 317 

after the accident occurs by use of a plaster cast and crutches. 
Ordinar}^ risks require from 8 to lo weeks of this disabihty fol- 
lowing a fracture involving the upper or middle third of this bone. 
When the fibula has been fractured, preferred risks whose duties 
demand the upright position require from 3 to 5 weeks of total 
disability. In the same class when the occupation is performed in 
a sitting position, total disability lasts from i to 2 weeks only. 
Ordinary risks demand from 3 to 6 weeks when a fracture of the 
upper or middle third of the fibula occurs. Fractures in which 
the tuberosities of the tibia have been separated, require from 6 
to 10 weeks of total disability in all classes of risks. Compound 
fractures involving the tibia or fibula usually prolong disability in 
all of the above classes from i to 4 weeks. 

PARTIAL DISABILITY of from 3 to 6 weeks is necessary 
in preferred risks when the fracture has involved the tibia and 
the duties of the occupation are performed in the upright position. 
In the same class when the occupation is inside this form of dis- 
ability lasts from 6 to 8 weeks following a fracture of this bone. 
If the fibula has been fractured, from 2 to 4 weeks of partial dis- 
ability are necessary in preferred risks when the duties require 
much walking. In the same class and with a fracture of a similar 
nature, partial disability of from 3 to 6 weeks is necessary in those 
whose duties are performed at a desk or in a sitting position. Or- 
dinary risks do not often ask for partial disability following a frac- 
ture of the fibula. 

EFFECTS : Fractures involving these bones with the ex- 
ception of the lower extremities, usually heal with little or no 
deformity and the individual is insurable for ah kinds of insurance 
from six to nine months after the date of accident if recovery has 
been complete and no complications have resulted. 

AMPUTATION OF THE LEG 

INFORMATION: Amputations of the leg between the 
knee and ankle are frequently performed as the result of acci- 
dental injuries which are caused by some heavy vehicle passing 
over one or both legs. These injuries are most commonly pro- 
duced by railroad trains, trolley cars and heavy machinery which 
so lacerate the soft tissues and destroy the circulation that repair 
is impossible. If a leg is amputated at or above the ankle joint 
within ninety days of an accidental injury, an insurance company 



318 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

is liable for the specified amount as stated in the policy for the 
loss of one leg. If both legs are lost or one leg and one arm, the 
company generally pays the face of the policy. Some companies 
pay weekly indemnity in addition to pa3ang this fixed amount. If 
a leg is not amputated until ninety days after the date of accident, 
the company would be liable for weekly indemnity only up to 
the time total disability ended, when partial disability would com- 
mence and this of course could be claimed to the limit of the 
poHcy. 

SIGNS AND SYMPTOMS : Injuries which result in ampu- 
tations so seriously damage the parts that the evidence is appar- 
ent; in addition there is pain, hemorrhage and severe shock. 

TOTAL DISABILITY lasts from 6 to 8 weeks in preferred 
risks Avhose duties are performed in a sitting position and the am- 
putation has been done at or near the ankle joint. In the same 
class when the duties are outside, total disability lasts from 8 to 
10 weeks following an amputation at this point. Preferred risks 
having a leg amputated through the shaft or upper part of the 
tibia, require from 8 to lo weeks when the duties of the occupa- 
tion are inside and no walking is necessary. In the same class, 
from 8 to 12 weeks are necessary when the amputation is done at 
this point and the occupation requires the upright position. Or- 
dinary risks require from 8 to I2 weeks of this disability and 
sometimes longer when the occupation consists of manual labor. 
Some cases of severe injuries involving the lowxr extremity are 
not amputated until considerable time has elapsed after the date 
of accident, and the above times are for disability commencing 
with the time the operation is performed. Infection is usual in al- 
most all these cases and is considered in this time. If both legs 
are amputated at the same time, disability is not prolonged, but if 
the second one is amputated from 3 to 6 or 8 weeks, after the 
first, the length of time disability lasts must be computed from the 
date of the last operation; the individual of course being totally 
disabled from the time of the accident up to the time the second 
operation is performed. 

PARTIAL DISABILITY is present in all classes suffering 
from the removal of one or both legs and remains during the life 
of the individual. 

EFFECTS: Individuals having suffered the loss of one or 
both legs are impaired risks for accident insurance and are not 
considered insurable by accident insurance companies. If only 



I 



FRACTURE INVOLVING THE ANKLE JOINT 



31» 



one leg has been removed the person is insurable for life or health 
insurance from six to nine months after the date of accident, — if 
recovery is complete. 

FRACTURE INVOLVING THE ANKLE JOINT 

INFORMATION: Fractures occurring in connection with 
injuries to the ankle joint are described as either a Pott's or Du- 
puytren's fracture. A Pott's fracture, which is most common, 
consists of a fracture of the fibula from one to three inches above 



' — 


1 

.1 ; 



Fig. 86. — Anterior view of deformity 
following Pott's fracture. (Keen). 



the lower extremity and a tearing off of the tip of the internal 
malleolus of the tibia, together with an outward dislocation of the 
foot. These fractures are usually due to direct force, wdien the 
foot turns outward and the strong deltoid ligament on the internal 
surface of the ankle tears off the tip of the internal malleolus and 
the fibula is bent inward, causing a fracture in its lower fifth. 

SIGNS AND SYMPTOAIS: The foot is markedly everted 
in a Pott's fracture and is badly swollen; this swelling extending 
a considerable distance above the ankle. There is pain on the 
slightest movement, tenderness on pressure over the points in- 



320 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

dicating the fractures, crepitation; loss of spring in the fibula, in- 
ability to rest an}' weight on the foot without great pain and dis- 
coloration which is so extensive that the whole foot and leg are 
involved. 

DIFFERENTIAL DIAGNOSIS: Dislocation outward of 
the ankle in which the upper articular surface of the astragalus is 
displaced outward, invariably accompanies a Pott's fracture, but 
as the fractured bones require a longer time for recovery than 
does the dislocation, the complication does not prolong disability. 
The dislocation is recognized by eversion of the foot, broadening 
of the ankle joint, impairment of motion and inability to stand on 
the injured leg. When a dislocation of this joint or fractures of 
some of the bones in connection with it occurs, the x-rays should 
be used for the proper diagnosis and also to ascertain if the bones 
have been properly reduced. 

COMPLICATIONS: Tuberculous Disease of the ankle joint 
may be present, and when a fall is sustained, a fracture occurs as 
a re^sult of the existence of this disease. In such cases, there is 
a history of pain in the joint, swelling without the typical dis- 
coloration due to an injur}^, limitation of movement, and if the 
disease has existed long enough to result in a fracture from 
slight violence, atrophy of the calf muscles is present and sinuses 
may also have formed around the joint as a result of the caseating 
process. An accident insurance company would not pay a claim 
for a fractured ankle if this disease was present and would not 
insure such an individual if the disease was known to have existed 
before the policy was taken out or developed after it was issued; 
the company either declining to issue the policy or cancelling it 
as soon as such facts become known. 

TOTAL DISABILITY lasts from 3 to 4 weeks in preferred 
risks when the duties can be performed in an office and do not 
require much walking. In the same class when the duties are 
outside and require constant use of the legs, total disability lasts 
from 6 to 8 weeks. Ordinary risks require from 8 to 10 weeks 
of this disability for this injury. Compound fractures involving 
the ankle joint cause long periods of disability, increasing the 
above time from 3 to 6 or 8 weeks and sometimes even longer. 

PARTIAL DISABILITY of from 2 to 4 weeks is payable to 
preferred risks when the duties of the occupation are inside. In 
the same class when the occupation is performed in the upright 



FRACTURES OF THE TARSUS AND METATARSUS 



321 



position, this partial disability lasts from i to 3 weeks. Ordinary 
risks do not often ask for partial disability. 

EFFECTS: A Pott's fracture of the ankle joint generally 
produces some impairment of motion in this articulation and this 
persists for some time. Usually, however, all forms of insurance 
can be offered such individuals from three to six months after 
complete recovery. 

FRACTURES OF THE TARSUS AND METATARSUS 

INFORMATION : Fractures involving the tarsal bones are 




FIG. 87.— COMPRESSION FRACTURES OF THE 
ASTRAGALUS AND OS CALCIS, FOLLOWING 
A FALL OF EIGHTY FEET. (Keen). 
F, Outline of fibula; T, tibia; a, posterior frag- 
ment of fractured astragalus. The various letters 
c represent the comminuted fragments of the 
fractured os calcis. 

not frequent, and when seen are usually the result of direct force, 
such as a crush of the foot which mav be received bv a heavv 



322 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

vehicle passing over it or being caught in machinery. Indirect 
violence sometimes causes a fracture of the os calcis or astraga- 
lus. Fractures of the metatarsal bones are of rather common oc- 
currence and almost invariably are the result of direct force; fre- 
quently being compound. 

SIGNS AND SYMPTOMS: Fractures involving the tarsal 
bones cause much swelling of the foot and ankle, followed by dis- 
coloration. There is pain, crepitus, unnatural mobility, sometimes 
an apparent widening of the foot and flattening of the arch, with 
tenderness on pressure over the fractured bones. If one or more 
of the metatarsal bones are fractured, deformity usually exists 
and the fractured ends are diagnosed by palpation; crepitus is 
present with pain, swelling and discoloration. 
Inability to stand on the injured foot is com- 
plained of in fractures involving the tarsus or 
metatarsus. 

TOTAL DISABILITY lasts from 4 to 6 
weeks in preferred risks when a fracture of 
some of the tarsal bones has occurred and the 
duties are performed without much walking. 
In the same class, from 6 to 8 weeks are neces- 
sary following a fracture of the same bones 
and the duties of the occupation are outside 
and considerable walking is required. Ordi- 
Fig. 88.-Transverse "^^7 ^isks arc totally disabled from 6 to 8 
STtTta°rsiT b?n£ ^ccks after, a fracture of the tarsal bones. 
(Scudder). Total disability in preferred risks whose occu- 

pation demands a sitting position, lasts from 2 to 3 weeks when 
a fracture of one or more of the metatarsal bones occur. In the 
same class and with a similar injury, total disability lasts from 4 
to 6 weeks when the occupation requires the upright position 
constantly or walking is necessary. Ordinary risks demand from 
4 to 6 weeks of total disabihty for fractures mvolving these bones. 
Compound fractures of any of the bones of the foot increase total 
disability in all classes of risks from i to 4 weeks. 

PARTIAL DISABILITY of from i to 3 weeks is payable 
to preferred risks suffering from a fracture of the tarsal or meta- 
tarsal bones and the occupation is outside. In the same class, 
from 3 to 6 weeks are necessary following a fracture involving 
any of the bones of the foot and the duties of the occupation are 




AMPUTATION OP THE POOT 323 

performed mainly in an office. Ordinary risks are not often en- 
titled to any partial disability when a fracture of any of these 
bones has occurred. 

EFFECTS : A sHght impairment of motion generally follows 
fractures of the tarsal bones, but this is not sufficient to withhold 
accident insurance and an individual who has suffered from a frac- 
ture involving any of the bones of the foot, is insurable for all 
kinds of insurance from three to six months after the date of ac- 
cident, provided recovery has been complete. 

AMPUTATION OF THE FOOT 

INFORMATION : Amputations of the foot are performed 
after accidental injuries when the foot has been so badly crushed 
or mashed by machinery, the passing over it of cars, heavy 
wagons, etc., that recovery is impossible without such an opera- 
tion. Accident insurance policies do not often pay a specified 
sum for the loss of a part of the foot, but simply pay the length of 
time total and partial disability lasts. If the amputation is per- 
formed at or above the ankle joint, a fixed sum is payable and 
this is increased by weekly indemnity during disability by some 
companies. Some insurance companies allow an "elective" in- 
demnity for the loss of a foot or the fracture of certain bones of 
the body. This is given in lieu of weekly indemnity. 

SIGNS AND SYMPTOMS : Following a crush of the foot, 
the injury is apparent and there is pain, hemorrhage, swelling, 
discoloration, loss of motion in the foot and toes involved and in- 
ability to rest any weight on the injured member. 

COMPLICATIONS: Septicemia may develop as the result 
of a badly lacerated foot or toes and cause disability to be greatly 
prolonged. This form of blood poisoning may become so severe 
that death results. If a fatal termination occurs within ninetv 
days after the date of accident, an insurance company would 
usually be liable for the full amount of an accident policy. 

Erysipelas sometimes develops after a foot has been badly 
torn and lacerated, but this complication seldom prolongs dis- 
ability. 

TOTAL DISABILITY lasts from 3 to 6 weeks in preferred 
risks whose duties are performed in a sitting position and the am- 
putation of part of the foot is performed after an injury in which 
the soft parts are not badly lacerated. In the same class and un- 



324 FRACTURES AND AMPUTATIONS OP LOWER EXTREMITY 



der the same conditions, total disability lasts from 6 to 8 weeks 
when the occupation requires the upright position and much 
walking. Ordinary risks are totally disabled from 6 to lo weeks 
following an amputation of any part of the foot between the toes 
and ankle. Infection prolongs the above time in all classes of risks 
from I to 3 weeks. 

PARTIAL DISABILITY follows an amputation in which 
the foot or part of one has been removed, and persists until an 
artificial foot can be fitted on to the stump and the duties of the 
occupation performed properly. Such cases usually require the 
iim.it of partial disabihty allowed by the policy, unless an elective 
indemnity has been accepted in payment of the claim. 

EFFECTS : Individuals suffering from an accident in which 
a part of one or both feet have been amputated, are impaired risks 
and are not insurable for accident insurance. Life or health in- 
surance can be safely issued to such persons from two to six 
months after complete recovery. 

FRACTURES OF THE PHALANGES OF THE TOES 

INFORMATION: Fractures involving any of the small 
bones of the toes are usually the result of direct force, such as the 
passing of a heavy vehicle over the toes or a crush due to ma- 
chinery or a heavy object falHng on the 
foot. These injuries are frequently 
compound and often result in amputa- 
tions on account of this complication. 

SIGNS AND SYMPTOMS: Frac- 
tures involving the phalanges of one 
toe almost invariably produce injuries 
to the adjacent toes or the foot, when 
there is swelling and discoloration, pain 
on movement and crepitation is easily 
elicited between the fractured ends of 
the bone. If the injury is a compound 
fracture, bleeding occurs. 

TOTAL DISABILITY lasts from 
2 to 7 days in preferred risks when the duties of the occupation 
do not require much walking Individuals whose occupation de- 
mands walking constantly during the day, require from 2 to 3 
weeks of this disability. Ordinary risks are totally disabled from 
2 to 3 weeks following a fracture involving one or more toes of 




Fig. 89. — Fracture of the 
first phalanx of the little toe. 
(Scudder). 



AMPUTATION OF THE TOES 325 

the foot. Compound fractures of the phalanges prolong disabil- 
ity in all classes from i to 2 weeks. 

PARTIAL DISABILITY of from i to 3 weeks is payable to 
preferred risks when the duties are inside and the length of total 
(disability has been very short. In the same class when the occu- 
pation requires the upright position and total disability has lasted 
from 2 to 3 weeks, partial disabiHty is seldom necessary. Ordi- 
nary risks are not often entitled to any partial disability. 

EFFECTS : Fractures of the bones of the toes heal readily 
and leave no impairment; the individual being insurable for all 
kinds of insurance from four to eight weeks after the date of acci- 
dent. 

AMPUTATION OF THE TOES 

INFORMATION: Amputation of one or more toes of the 
foot may result when a compound fracture has occurred or when 
the toes have been so badly crushed and lacerated by a heavy 
weight falling on them that repair is impossible. Amputations 
resulting in the loss of one or more toes are almost invariably ac- 
companied by injuries to some other part of the foot or other 
toes. Generally the toe which is the most badly mangled is the 
one amputated and the adjacent ones are saved. Malingerers 
select the toes of either foot for mutilation more often than any 
other part of the body and when a toe has been intentionally mu- 
tilated or cut off, the injury invariably involves the single toe 
which is destroyed and the surrounding parts are not harmed, as 
when the injury occurs accidentally. Such individuals always 
carry a number of insurance policies, but deny having more than 
one. They allege, the accident occurred, — if possible, — under the 
doubling clause of the policy and always when no witnesses are 
present. Examination of the same foot or opposite one frequently 
shows that the parts of one or more toes have been amputated 
and no evidence of any previous injury to the foot — except to 
the amputated one — is apparent. 

SIGNS AND SYMPTOMS following an injury to the foot 
which may result in an amputation of one or more toes, shows an 
injury most seriously involving the. toe which must be amputated, 
the other toes and part of the foot also being concerned in the ac- 
cident. The evidence of such an injury is apparent and is accom- 
panied by pain, tenderness on pressure, swelling and discolora- 
tion of the adjacent parts. 



326 FRACTURES AND AMPUTATIONS OF LOWER EXTREMITY 

DIFFERENTIAL DIAGNOSIS: Self Mutilation is prac- 
ticed by some individuals for the purpose of gain, and in these 
cases the toes are most often selected for amputation. In such 
instances, as small a part of the toe as possible is taken off. In- 
surance policies only pay weekly indemnity when the disability 
is due to the loss of a small part of a toe, but when one whole 
phalanx is amputated, the policy sometimes provides an elective 
indemnity; malingerers, therefore, cut off the toe at the terminal 
joint. These injuries never occur in the presence of witnesses; 
are usually alleged to have happened in a manner entitling the 
claimant to double indemnity and no injury to the surrounding 
toes or foot occurs. Examination of the opposite foot or hands 
often shows the loss of the terminal phalanx of one or more toes 
or fingers and the individual is carrying a number of accident in- 
surance policies, although it is claimed only one such policy is in 
existence. . 

TOTAL DISABILITY lasts from 3 to 6 weeks in all classes 
of risks when one or more toes are amputated and no complica- 
tion exists. Fractures of the bones of the foot or injuries to other 
toes may complicate and prolong this disability. L^sually, how- 
ever, the above time is sufficient if an operation is performed 
within a few days following the accident. 

PARTIAL DISABILITY is present in preferred risks when 
the occupation requires much walking and lasts from i to 2 
weeks. This time is increased when the great toe has been am- 
putated and may persist from 4 to 8 weeks or longer, or until 
the individual learns to walk without the use of this member. 

EFFECTS : Individuals suffering the loss of any toes from 
the second to the fifth inclusive, are insurable for all kinds of in- 
surance from one to two months after complete healing of the 
parts. When the great toe has been amputated, accident insur- 
ance would hardly be considered by an insurance company until 
at least three to six months had elapsed after complete recovery 
of the injury. Life or health insurance, however, could be safely 
written from one to two months after complete healing of the 
stump. 



CHAPTER XII 

ILLNESSES CAUSING DISABILITY 

DISEASES OF THE SKIN 

FURUNCULUS 

SYNONYMS: Boil; furuncle; furunculosis. 

INFORMATION: A furuncle or boil is a localized collec- 
tion of pus in the skin and shows itself by an area of inflammation 
and induration, the centre of which is usually a hair follicle or a 
sebaceous gland. This circumscribed area of inflammation is 
caused by the staphylococcus pyogenes aureus and is more com- 
mon in certain diseases, such as diabetes, tuberculosis, indigestion, 
anemia and Bright's disease and is sometimes the result of injuries 
to the skin in which the nutrition is impaired and the staphylocci 
gain access and start an inflammation. Boils are more frequently 
seen on the face or neck, in the axillae, around the nipples, anus or 
labise, or on the back, buttocks and perineum. 

SIGNS AND SYMPTOMS: A boil commences by a small 
spot which itches and stings. This gradually enlarges and is ac- 
companied by induration and an area of inflammation that is 
tender on pressure and in which a throbbing pain is located. In 
about a week's time, the abscess becomes *''ripe" and at the center 
of the swelling there appears a yellow covering which ruptures 
and allows a discharge of pus. Several days later, the core or 
necrosed central part of the boil is discharged through this open- 
ing and healing commences. This is accomplished by the cavity 
filling up with granulation tissue and being covered over by a 
scar or cicatrix which becomes white and usually persists. Furun- 
cles which do not suppurate are known as ''blind" boils. Consti- 
tutional symptoms are slight when only one boil exists, but if a 
number of them are present, grave signs and symptoms may re- 
sult and imperil the life of the individual. 

DIFFERENTIAL DIAGNOSIS : Carbuncles are often mis- 
taken for boils in the early stages, but these are usually situated 

327 



328 DISEASES OF THE SKIN 

where the connective tissue is thick and dense, such as the back 
of the neck, the back or buttocks and occupy a large area which 
is highly inflamed, tender on pressure and very painful. Car- 
buncles occur singly and have a number of foci of infection and 
discharge pus from several points; no core is present, but the 
whole part becomes necrosed tissue and requires removal. 

COMPLICATIONS : Boils often indicate the existence of a 
constitutional disease, and if seen in an individual who is carrying 
a health policy, the urine should always be examined to ascertain 
if diabetes or Bright's disease is present. 

HOUSE CONFINEMENT is not necessary when one or 
more small boils exist, but if several large ones are present at the 
same time or they appear in crops, house confinement may last 
from I to 2 or 4 weeks; this time depending on the size and se- 
verity of the furuncle and often on the co-existing constitutional 
disease which may be present. 

TOTAL DISABILITY of i week is usually sufficient in all 
classes of risks suffering from one or more boils. If a number of 
these are present or occur in crops, and house confinement lasts 
from one to two weeks, total disability of from i to 3 weeks is 
necessary. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is sometimes payable after an individual has suffered from a num- 
ber of boils which have occurred either singly or in crops, and i 
to 3 weeks may be demanded for the time spent in recuperation 
before return to work is possible. Some health policies only pay 
for house confinement and therefore in such cases this form of 
indemnity would not be payable. Other poHcies only pay a frac- 
tional part of the total disabihty for time spent in recuperation, 
and this point must be borne in mind in settling such cases. 

EFFECTS : Individuals with a history of having suffered from 
a number of boils are not insurable for any kind of a poHcy until 
after an examination of the urine has been made and it has been 
found normal. If a few boils only have occurred during the life 
time, insurance of all kinds can usually be issued two to four 
weeks after the date of the last one. 

CARBUNCULUS 

SYNONYMS: Carbuncle; anthrax. 

INFORMATION: A carbuncle is a circumscribed inflam- 



CARBUNCULUS 329 

mation of the skin and deeper tissues and is said to be caused in 
some cases by deep bruises; the injury lowering the vitahty of the 
tissues and the micro-organism which causes this inflammation 
gains access through the blood current and produces suppuration. 
Carbuncles are most often seen on the neck, back or buttocks, and 
are more common in men than in women. They frequently occur 
in individuals suiTering from diabetes and those whose general 
health is below par. 

SIGNS AND SYMPTOMS: A carbuncle is often described 
as a collection of boils in a small space and commences by a nodu- 
lar swelling which has scattered over its surface small vesicles. 
This sweUing soon enlarges, becomes dusky in color and is the 
seat of severe pain and tenderness on pressure. After seven to 
ten days, a number of points of infection appear and break down, 
discharging small quantities of pus, and when the carbuncle in- 
volves a large area, these foci of infection coalesce and form one 
large oedematous mass of necrosed tissue. Constitutional symp- 
toms are always present in this disease, the severity of which de- 
pends on the area and depth of the carbuncle. There is malaise, 
loss of appetite, coated tongue, fever, and in some cases septi- 
cemia follows : 

DIFFERENTIAL DIAGNOSIS: A Furuncle is often diag- 
nosed as a carbuncle in the early stages, but after a few days the 
constitutional symptoms, together with the increasing area of in- 
ilammation surrounding it and the appearance of several points of 
infection, tend to show that the inflammation is more than a boil 
and a carbuncle is developing. 

COMPLICATIONS: Septicemia may compHcate any car- 
buncle and result in symptoms characteristic of this infection. If 
this exists, death frequently occurs and disability is shortened 
thereby. 

HOUSE CONFINEMENT lasts from i to 3 weeks when 
the carbuncle occupies a small area and systemic S3aTiptoms are 
not marked. Those of a larger size require confinement to bed 
and the house from 3 to 6 weeks. This time is increased 2 to 4 
weeks when the disease occupies a very extensive area and sev- 
eral operations for the removal of the sloughs are necessary. 

TOTAL DISABILITY of from 2 to 4 weeks is payable to 
preferred risks sufTering from small carbuncles. When the dis- 
ease has been extensive, the time required for this disability is 
from I to 3 weeks longer than house confinement. Ordinary risks 



330 DISEASES OF THE SKIN 

are usually totally disabled from i to 2 weeks longer than pre- 
ferred risks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable in addition to house confinement and total disability, 
usually requires from 2 to 4 weeks; this time depending on the 
occupation of the individual, the location and extent of the car- 
buncle, the age and physical condition. 

EFFECTS : Individuals having suffered from a carbuncle in 
which there is no history of any previous ones existing and ex- 
amination of the urine shows it to be normal, are insurable for 
all kinds of insurance from one to four months after complete re- 
covery and healing of the parts. Accident and life insurance can 
usually be written at the same time on such individuals, even 
though there is a history of more than one carbuncle, provided the 
excretion from the kidneys is normal. 

ECZEMA 

SYNONYMS: Tetter; scall; salt rheum. 

INFORMATION: Eczema is a non-contagious, catarrhal, 
inflammatory disease of the skin which attacks individuals and 
may be acute or chronic. Eczema rarely causes total disability, 
unless involving a large area of skin or it is found around the 
genitals. Acute cases of this disease are seldom severe enough 
to cause house confinement or loss of time from business, and in- 
dividuals having once suffered from this disease would not be in- 
surable if a history of such was given on the application. There- 
fore, claims arising as the result of eczema are not often covered 
by an insurance polic}^, for the reason that the disease almost in- 
variably existed before the application was taken out and if no 
mention of it was made at the time the policy was applied for, a 
breach of w^arranty exists and insurance companies are not liable 
for such claims. 

SIGNS AND SYMPTOMS vary according to the location 
and variety of the disease. There is usually some swelling, with 
heat and formation of blisters which rupture and are covered by 
a yellowish crust. The skin is a mottled, reddish hue, harsh, dry 
and thickened with areas that are constantly wet from oozing. 
Burning and itching of the parts involved are the most constant 
and annoying symptoms of this disease. 

DIFFERENTIAL DIAGNOSIS : Herpes Zoster resembles 



ECZEMA 



331 



this disease, but herpes are usually found situated over the course 
of a nerve, and these blisters are accompanied by intense neuralgic 
pain which is absent in eczema The duration of herpes is a few 
days only, while eczema lasts an indefinite time. 

Erysipelas in the early stages might be confounded with ec- 
zema, especially when there is an existing history of this latter 
disease. Erysipelas, however, is accompanied by high fever, in- 
tense inflammation and redness of a circumscribed area; the cir- 
cumference of which is well marked and is readily felt by the 
lingers. 

HOUSE CONFINEMENT lasts from i to 2 weeks in all 





Fig-. 90. — Eczema of leg with varicose ulcers. (Stelwagon). 

classes of risks suffering from this disease involving the genitals 
and internal surfaces of one or both thighs. 

TOTAL DISABILITY lasts from i to 3 weeks in all risks 
who are disabled by this disease, and this time is payable if the 
disease has not occurred previousl}^ If it has been present and 
the company is not in possession of these facts, it is questionable if 
an individual would be covered for the time disability existed. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is rarely payable to any class of risks following an attack of this 
disease, either in the acute or chronic form. 

EFFECTS: Individuals subject to eczema almost invariably 
suffer attacks of this disease from time to time, but as this has no 



332 



DISEASES OF THE SKIN 



I 



effect on the longevity or production of accidents, life or accident 
insurance could be safely issued to such persons as soon as recov- 
ery ensues. Health policies, however, would not be written un- 
less a waiver eliminating disability for this disease was attached. 

FELON 

SYNONYMS: Whitlow; paronychia; ring-around; bone 
felon. 

INFORMATION : A felon is an inflammation involving the 
skin surrounding the base of the nail or is deeper seated and the 
bone and periosteum are affected. Felons are said to follow in- 
juries of some character, when pus-organisms gain access to the 
tissues and result in a superficial or deep felon. This affection in- 




Fig-. 91. — Deep felon, with sloughing of soft parts and 
necrosis of bone. (Da Costa). 

volves the toes and fingers and is more common in the latter; 
usually affecting the last digit of a finger or thumb. 

SIGNS AND SYMPTOMS: Superficial felons are gener- 
ally found around the base of a nail, when there is a semi-circu- 
lar swelling in this situation accompanied by a purplish-red dis- 
coloration of the skin, with pain and tenderness on pressure. This 
condition continues until the pus is evacuated by an opening be- 
tween the nail and skin or through an incision. A bone felon 
commences by swelling of the finger which gradually increases 
and is accompanied by pain of an intense, throbbing character 



FELON 333 

which is worse at night and when the hand is in the dependent 
position. The finger is extremely tender and a reddish discolora- 
tion with heat is present. These signs and symptoms are not 
abated until a deep incision is made and the pus discharged. 
Systemic symptoms, such as loss of appetite, inability to sleep 
and fever are present in cases suffering from bone felons. 

COMPLICATIONS: Necrosis of the terminal phalanx of 
the affected finger or thumb sometimes occurs with this affection, 
and removal of this part of the bone is necessary, thus prolonging 
disability and resulting in a permanently deformed finger. 

Tenosynoviiis almost invariably complicates a bone felon, but 
is usually confined to the digit affected. This inflammation, how- 
ever, — when the thumb or little finger is involved, — may extend 
into the palm of the hand and result in a palmer abscess, when 
disability will be greatly prolonged. 

HOUSE CONFINEMENT does not exist in superficial 
felons. Bone felons are sometimes so severe that the individual 
remains part of the time in bed, and in such cases house confine- 
ment lasts from 5 to 10 days in all classes of risks. 

TOTAL DISABILITY is not payable to any claimant suf- 
fering from a whitlow or superficial felon. Preferred risks are 
sometimes totally disabled from i to 2 weeks when a severe bone 
felon has existed and involved the fingers or thumb of either hand. 
Ordinary risks generally require from i to 3 weeks of this dis- 
ability, the length of time depending on the exact duties of the 
occupation, severity of the infection and treatment. Bone felons 
resulting in necrosis of the terminal phalanx and causing an am- 
putation of this part, prolong disability from 2 to 3 weeks in pre- 
ferred risks when the felon involves the right hand and the duties 
require the constant use of this extremity. If a felon involves the 
left hand and amputation of the end of the finger or thumb is 
necessary, total disability seldom lasts longer than from i to 2 
weeks. Total disabihty is greatly prolonged when a palmer ab- 
scess results and involves the right hand, and this is described 
under Palmer Abscess. 

PARTIAL DISABILITY of from i to 3 weeks is some- 
times payable to preferred risks suffering from a whitlow or ring- 
around when the claimant carries an accident policy and the in- 
fection follows an accidental injury. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY: 
If a claimant must be confined to the house to be entitled to total 



334 



DISEASES OF THE SKIN 



disability, partial indemnity for total disability — if provided by the 
policy — is sometimes payable after this period of house confine- 
ment, and may require from i to 2 weeks when the individual has 
suffered from a severe bone felon. Superficial felons do not pro- 
duce sufficient disability to entitle a person to any partial indem- 
nity for total disability, for the reason that this form of indemnity 
is only payable after a period of total disability, and this is never 
caused by this form of felon. 

EFFECTS : None, if the claimant has fully recovered and 
has not lost the use of the finger or any part of it. If the end of 
the finger is taken off for any reason, some impairment exists, but 
is not sufficient to prevent insurance of all kinds being issued. 

HERPES ZOSTER 



zona. 



SYNONYMS: Shingles; a girdle; intercostal neuralgia; 
INFORMATION: Herpes zoster is the external manifesta- 




Fig. 92. — Herpes zoster involving chest, side and 
back. (Church and Peterson). 



tion of an inflammation of some of the nerves of the body. It 
usually occurs over the intercostal nerves, most often involving 
the third, fourth and fifth, and is unilateral; sometimes it affects 
one whole side, from the middle line of the body in front to the 



VARICOSE ULCER 335 

middle line behind. It consists of a line of pearly blisters following 
the course of the inflamed nerve or nerves and is supposed to be 
caused by exposure to cold or dampness, prolonged use of arsenic, 
injuries, and by some diseases, such as anemia and malaria. 

SIGNS AND SYMPTOMS: This affection begins by neu- 
ralgic pain over the nerve affected, accompanied by a very slight 
elevation of temperature, and this is soon followed by the forma- 
tion of discrete vesicles that are first filled with a clear, watery 
fluid which soon becomes a yellowish tinge. These vesicles ap- 
pear in groups and are usually the size of a pin's head; after per- 
sisting several days, rupture of the vesicles takes place and they 
coalesce, forming irregular patches that are covered by yellowish 
scales. The neuralgic pain which precedes the rupture persists 
and may even last after the vesicles have entirely disappeared. 
This affection is self limited, disappearing in one to two weeks. 

HOUSE CONFINEMENT is not necessary and is not pres- 
ent in mild cases of this disease, but severe ones require from i 
to 2 weeks inside the house, and frequently this time must be 
spent in bed. 

TOTAL DISABILITY should not be paid to any class of 
risks suffering from a mild case of herpes, but when the disease 
has been severe enough to cause house confinement for some 
days, total disability of from i to 2 weeks is necessary. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment should seldom be paid to any class, as the disease is either so 
mild that total disability does not occur or is sufficiently severe 
to cause absolute confinement to the house, when total disability 
is present. 

EFFECTS : Individuals having suffered from herpes involv- 
ing any part of the body are insurable for any kind of a policy 
from one to two months after complete recovery, provided there 
is no history of previous attacks of this disease. If such a condi- 
tion has existed, an insurance company would not accept a risk 
with this history for health insurance unless a waiver was placed 
on the policy eliminating the payment of indemnity for this af- 
fection. 

VARICOSE ULCER 

SYNONYMS: Chronic ulcer; eczematous ulcer; hemor- 
rhagic ulcer. 



336 DISEASES OF THE SKIN 

INFORMATION : An ulcer forming on any part of the body, 
and especially on the lower extremities between the knee and 
ankle, when in conjunction with an eczematous condition of the 
skin or varicose veins, is known under one of the above names. 
These ulcers usually occur in persons past middle age and result 
from the slightest scratch or blow to the part of the body af- 




Fig-. 93. — Varicose ulcer of leg. (Eisen- 
drath). 



fected with eczema or a number of dilated veins, and in almost 
every case there is a history of previous ulcers. An insurance 
company would not accept an individual for accident or health 
insurance with a history of having suffered from a varicose ulcer 
of the leg or having a condition that would result in such an ulcer 
when an injury was sustained. Therefore, claims for indemnity 



VARICOSE ULCER 337 

alleging the cause as due to an ulcer of the leg are almost invari- 
ably claims for disability resulting from chronic or varicose ulcers, 
and unless mention has been made in the appHcation of such a 
condition existing, there is a breach of warranty, and an insurance 
company is not Hable for indemnity under such conditions. 

SIGNS AND SYMPTOMS: Eczematous ulcers are most 
common in men after fifty years of age and more frequently af- 
fect that part of the leg within six to eight inches above the 
ankle. These ulcers form when there is an eczematous condition 
of the skin or the superficial veins are dilated. In such cases 
there is a reddish discoloration and engorgement of the skin which 
breaks down and bleeds from a slight scratch or blow. This small 
abrasion results within a few days to a week in an ulcer varying 
in size from a half to one or two inches in diameter with a red, 
bleeding base, thick, swollen, sloping edges, and later is covered 
by exuberant granulations 'and discharges pus which irritates the 
surrounding tissue. This condition persists and responds exceed- 
ingly slow to all kinds of treatment. 

'differential DIAGNOSIS: Syphilitic Ulcers situated 
on the lower extremities are the only form of ulcers which may 
be mistaken for an ulcer due to a local condition. These ulcers 
are preceded by a history of specific infection and the signs and 
symptoms which follow that infection. Syphilitic ulcers occur in 
the second or third stages of this disease and are usually circular 
or crescentic in shape with a punched-out appearance, the edges 
undermined and the circumference surrounded by an area of in- 
flammation, while the base of the ulcer is generally covered with 
a slough. When such an ulcer heals, it does so under systemic 
treatment and usually leaves a depressed, white scar. An insur- 
ance company would not be liable for indemnity under an acci- 
dent policy if disability resulted from this form of an ulcer and 
when a general disability policy is carried, it usually exempts dis- 
ability from venereal diseases. 

HOUSE CONFINEMENT is extremely uncertain in cases 
of varicose ulcers. When the sore is small and the surrounding 
tissue is fairly good, house confinement does not exist at all, but 
when the ulcer is one to tv/o or three inches in diameter and much 
dilatation of the veins exists with perhaps an eczematous con- 
dition of the skin, house confinement lasts from 2 to 4 or 6 weeks 
and oftentimes much longer; this depending greatly on the con- 
dition of the skin of the leg on which the ulcer is found: the phy- 
22 



338 DISEASES OF THE SKIN 

sical condition of the individual, the opportunity for treatment and 
the treatment itself. 

TOTAL DISABILITY, if payable to a claimant who secured 
a policy when the conditions were normal, lasts according to the 
size of the ulcer and the period of house confinement which fol- 
lows. Small ulcers which occur for the first time on a leg in such 
a condition, should not cause total disability of more than i to 2 
weeks. Large ulcers which result from an abrasion or contusion 
to the leg and break down rapidly, cause total disability of from 
3 to 6 or 8 weeks and sometimes longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY, 
if payable by the policy after the termination of house confine- 
ment may also be uncertain; depending on the condition of the 
leg and the ulcer at the termination of this period; usually, how- 
ever, from I to 2 or 3 weeks are sufficient. 

EFFECTS: Individuals with an impaired condition of the 
skin of the lower extremities or with a history of having had one 
or more ulcers in this situation, are not insurable for an acci- 
dent or health policy, even though a waiver be placed on the 
policy eliminating indemnity for this disability, for the reason that 
such individuals are addicted to excesses of various kinds and 
generally come from the lower walks of life where the sanitary 
surroundings are poor and a constant struggle for existence is 
necessary. Life insurance also would hardly be issued to such 
persons. 



CHAPTER XIII 

DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

APOPLEXY 

SYNONYMS: Cerebral hemorrhage; cerebral apoplexy; a 
stroke. 

INFORMATION: Cerebral hemorrhage results from the 
rupture of a blood vessel in some part of the brain and the re- 
sulting pressure on account of free blood on the brain substance 
causes unconsciousness and paralysis. It usually occurs after forty 
years of age, but is not uncommon before that time and is due to 
disease of the walls of the arteries. Apoplexy is most frequent 
in chronic alcoholics, those suffering from Bright's disease, syphi- 
lis, rheumatism and gout and is more often seen in the spring 
and fall. The attack is usually caused by excesses of some kind, 
such as over-indulgence of alcohol or food, mental or physical ex- 
citement, lifting, straining and in rare instances by traumatism, 
either at the time of the accident or several days later, but in these 
cases arterial degeneration has been existing for some time. 

SIGNS AND SYMPTOMS : Attacks of apoplexy are gener- 
ally preceded by prodromes of headache, vertigo, tinnitus 
aurium, disturbed sleep and rarely a sense of numbness and weak- 
ness on the side about to be affected The attack itself is sudden 
in onset, producing early unconsciousness or at once, thus causing 
the individual to fall. The face is flushed, respiration is noisy, 
slow and irregular, with a puffing outward of the paralyzed cheek; 
the pulse is full and slow; relaxation of the muscles is present 
with paralysis of the parts affected. The pupils do not react to 
light and the temperature is subnormal in the beginning, but 
within twenty-four to thirty-six hours, rises two to three degrees. 
Cases which quickty terminate fatally, have high temperature 
within a short time after the hemorrhage occurs. 

DIFFERENTIAL DIAGNOSIS. Syncope or Faiiifiiig is due 
to a failure of the circulation which produces unconsciousness, 
but in such cases the face is pale and ghastly white, in contradis- 
tinction to the flushed face in an apoplectic seizure. The pulse is 

339 



340 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM 



feeble in fainting, while in apoplexy it is slow and full. Respira- 
tions are quiet and unconsciousness persists for a short time only 
in syncope. 

Alcoholic Coma produces unconsciousness which is not so 
complete as apoplexy; the pulse is frequent, pupils react to light 
and ammonia held under the nose produces discomfort. "Firm 
pressure on the supraorbital notches with a steadily increasing 
force, will terminate unconsciousness when due to alcohol in al- 
most all cases." (Dr. Von Wedekind's test.) 

Opium when taken in poisonous doses causes a gradual in- 
creasing unconsciousness with contracted, pin point pupils which 




Fig. 94. — Hemorrhage into the internal capsule 
and the caudate and lenticular nucleus of the 
right cerebral hemisphere (from Bollinger). 



do not react to light, shallow respirations and slow pulse In 
coma from this drug the individual can be aroused, but immedi- 
ately lapses into unconsciousness again. 

Uremic Coma may be mistaken for coma due to cerebral apo- 
plexy, but if a history is obtainable it will be learned that convul- 
sions have preceded the period of unconsciousness and the indi- 
vidual has suffered from Bright's disease for some time The 
pupils are not drawn to the affected side as in apoplexy and the 
temperature in uremic coma rises rapidly, reaching 104° F or 
over, and this is not seen in apoplexy unless a fatal termination 
rapidly occurs. If a specimen of urine can be obtained, it will be 
found almost solid with albumin. 



EPILEPSY 341 

Sun Stroke produces coma, but in many such cases a history 
of exposure to heat can be elicited before the individual becomes 
unconscious. After this period is reached, the face is flushed and 
the surface of the skin hot and burning; the pulse is quick and 
the breathing either shallow or labored. Temperature rapidly 
rises, reaching 105° to 108° F and even going as high as 110° F, 
when death usually terminates the case. 

COMPLICATIONS are generally described under sequelae. 
Paralysis involving different parts of the body is the most im- 
portant sequelae and is present to a more or less degree in all 
cases, manifesting itself by the peculiar signs and symptoms of 
the part involved. 

HOUSE CONFINEMENT lasts from 5 to 14 days in mild 
cases of apoplexy. When the hemorrhage has been severe and a 
period of unconsciousness persists for a few hours to several days, 
house confinement lasts from 2 to 4 weeks. 

TOTAL DISABILITY is present and persists from i to 3 
or 6 weeks; this time depending on the severity of the attack, ex- 
tent of paralysis and the rapidity with which recovery follows, 
the occupation and financial condition of the insured. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
of from 2 to 4 weeks is payable, when the policy provides this 
form of indemnity for convalescence following a period of total 
disability after the ending of house confinement. 

EFFECTS : Individuals having once suffered from an attack 
of apoplexy are not insurable for any kind of a policy, and if an 
accident or health policy is carried by such a person, good under- 
writing demands that it be cancelled at once, as the cause which 
produced the cerebral hemorrhage remains and another one may 
take place at any moment. 

EPILEPSY 

SYNONYMS: Fits; convulsions; idiopathic epilepsy; fall- 
ing sickness; grand mal. 

INFORMATION: Epilepsy is a chronic disease which 
usually originates in early life and persists for years, sometimes, 
however, yielding to treatment and almost disappearing, but 
most frequently becoming worse as age advances. Epileptics 
generally suffer from chronic indigestion and are prone to con- 
tract diseases of the kidneys or lungs. Accidents due to attacks 
of epilepsy in which the individual falls unconscious and injures 



342 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

himself in the fall or is hurt by other means, are not covered by an 
accident policy. Should the party be in possession of a general 
disabihty policy, it is a foregone conclusion that such a policy has 
been obtained by withholding a history of epilepsy, as no insur- 
ance company would issue such a policy to any one who had 
ever suffered from this disease, consequently, if a claim should 
arise under a general disability policy, an insurance company 
could decline to pay it and would have sufficient grounds for de- 
fending its action. 

SIGNS AND SYMPTOMS: An attack of grand mal comes 
on suddenly and is usually preceded by a more or less pronounced 
aura and in such cases, epileptics are sometimes able to prevent 
a seizure. As an attack develops, the individual falls unconscious 
with a peculiar cry, the face is blanched, froth exudes from the 
mouth and biting of the tongue occurs unless something is 
placed between the teeth to prevent such an accident. Clonic 
convulsions of the muscles are seen and coma lasting from a few 
minutes to several hours ensues, when the individual awakens 
with a confused idea as to the surroundings, but generally with 
an improved mental condition. When epilepsy follows an injury, 
an attack may first occur within thirty to ninety days after the 
blow to the head is received, but usually not until at least one year 
has elapsed and these attacks differ from those seen in epilepsy 
existing from childhood. 

DIFFERENTIAL DIAGNOSIS is not difficult in these 
cases, as attacks in all individuals are practically the same and 
when once seen the diagnosis is easy. Uremic convulsions might 
be mistaken for epilepsy, but the history and a urinary analysis 
would soon make the diagnosis clear. 

COMPLICATIONS: Accidents involving some part of the 
body occur very frequentl)^ in epileptics and these injuries may 
be slight or severe; depending upon the position in which the in- 
dividual is placed v/hen the attack takes place. Disability from 
these accidents, however, is not covered by an accident or dis- 
ability policy. 

HOUSE CONFINEMENT does not exist in this disease, 
except in cases of very severe epilepsy which usually occurs in 
young folks and the individual is placed in a hospital and con- 
fined for the purpose of watching the disease and to prevent 
external injury during a seizure. 

TOTAL DISABILITY : None. Attacks of this disease sel- 



LOCOMOTOR ATAXIA 343 

dom last over three to four hours, when the individual awakens 
much relieved and with the mental condition improved. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY: 
None. 

EFFECTS: Epileptics are not insurable for any kind of a 
policy and if found insured, the policy should be cancelled at once. 
Insurance companies assume risks on such persons for all kinds 
of insurance when a history of epilepsy existed and no convulsion 
has occurred for ten to fifteen years. In such cases, the person 
is considered an average risk; all other conditions being normal. 

LOCOMOTOR ATAXIA 

SYNONYMS: Posterior spinal sclerosis; tabes dorsahs. 

INFORMATION: Locomotor ataxia is a chronic disease 
of the nervous system, especially affecting the posterior columns 
of the spinal cord and the posterior nerve-roots. It occurs more 
frequently between the ages of twenty and fifty years, is much 
more common in men than in women and syphilis is said to be 
the cause of the greater percentage of cases, although sexual 
excesses and alcohohsm, with exposure, are contributing factors. 

SIGNS AND SYMPTOMS depend on the stage of the dis- 
ease. When it first shows itself, there is a loss of sensation in the 
feet and lower limbs, associated with sharp, lancinating pains 
which appear in paroxysms. These are soon followed by loss of 
power of co-ordination in the fingers and feet and is first noticed 
when the individual is unable to touch the face with the fingers 
and the eyes are closed, and ''Romberg's" symptom which is in- 
ability of the individual to remain in the erect position with the 
eyes closed and heels together. A characteristic gait is always 
seen — that of throwing the feet forward and bringing them down 
forcibly. A sense of constriction around the abdomen, known 
as the "girdle sensation," is present, and is accompanied by se- 
vere pain. The Arg3dl-Robertson pupil which fails to react to 
light, but which accommodates itself for distance is present in all 
these cases. The knee jerk is absent early in the disease and 
later other reflexes may become abolished. The disease may be- 
come progressive for some time, until it finally causes death or it 
may be stopped and remain quiescent for a number of vears. 

DIFFERENTIAL DIAGNOSIS : Cerebellum disease in the 
early stages might be confounded with ataxia, but in the former 
there is headache, vertigo, nausea, vomiting and optic neuritis: 



344 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

while the reflexes are present and neuralgic pains and eye symp- 
toms are absent. 

Chronic Myelitis begins gradually with burning, tingling and 
numbness in the lower extremities and is of slow duration. The 
reflexes are generally exaggerated in this disease and no wasting 
of the muscles occurs, but the sphincters are affected early. 

Multiple Neuritis is characterized by tenderness over the 
peripheral nerves; absence of lancinating pains, the Argyll-Rob- 
ertson pupil, Romberg's sym.ptom and the patellar reflex. 

HOUSE CONFINEMENT: This disease is of such slow 
onset that house confinement never exists in the early stages, 
and when present, is evidence that the disease has been existing 
for months or years. Therefore, if an individual is carrying a 
general disability policy and unless it was issued a considerable 
time before house confinement is claimed, the claimant would 
hardly have a valid claim against an insurance company. 

TOTAL DISABILITY almost never exists until the last 
stage of this disease, when the individual suffers from extensive 
loss of co-ordination of different muscles of the body and paraly- 
sis. In rare cases, total disability lasts from i to 3 or 5 years, at 
the end of which time an improvement seems to occur and the 
individual is able to resume light duties. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
should never be paid by an insurance company, for the reason 
that partial disability precedes a period of total and may last from 
I to 5 or 10 years. The intent of an insurance policy is to pro- 
vide indemnity for total disability during convalescence, and fol- 
lowing a period of total disability which causes house confine- 
ment, and this condition is never present in this disease. 

EFFECTS : An individual is never insurable for any kind 
of insurance with a history of having once suffered from locomo- 
tor ataxia. 

PROGRESSIVE ' MUSCULAR ATROPHY 

SYNONYMS: Chronic poliomyelitis; wasting palsy; 
chronic spinal muscular atrophy; amyotropic lateral sclerosis. 

INFORMATION: This disease is a chronic affection in 
which the ganglion-cells in the anterior horns of the spinal cord 
degenerate and produce a progressive motor paralysis and atro- 
phy of certain groups of muscles. It is more common between 
the ages of twenty and fifty years and is said to be due to ex- 



PROGRESSIVE MUSCULAR ATROPHY 345 

posure to cold, over-exertion, lead poisoning, syphilis and rarely 
to injuries of the brain and spinal column. 

SIGNS AND SYMPTOMS: The onset of progressive mus- 
cular atrophy is so gradual that the diagnosis is not often made 
until it has existed for several months or more, when small fibril- 
lary contractions of the muscles affected occur on the slightest 
excitement. This is accompanied by pallor of the skin, loss of 
sensation, numbness and vi^asting of the muscles involved. As 
the disease progresses, the wasting becomes so pronounced that 
the body seems to be composed only of skin and bone. 

DIFFERENTIAL DIAGNOSIS: Idiopathic Muscular Atro- 
phy is a hereditary disease which occurs in children and affects 
the larger muscles of the body and in which fibrillary tremors 
are lacking. 

Syringomyelia in the early stages might be confounded with 
progressive muscular atrophy, but when it is remembered that 
this disease is nearly always bilateral and is accompanied with a 
loss of sensation to heat and cold and trophic changes in the skin, 
an error is not often possible. 

HOUSE CONFINEMENT: The onset of this disease is so 
gradual that it does not produce house confinement until after 
it has existed for months or years, at which time the final stage 
is reached and an insurance company would not have a policy on 
the individual unless it has been issued years before and no claim 
had ever been made for any disability, thus preventing the com- 
pany from knowing that such a disease existed. 

TOTAL DISABILITY only occurs in the last stages of 
progressive muscular atrophy and the duration of this is very un- 
certain, sometimes lasting a few months only and again for sev- 
eral years; this being due to the fact that the disease is occa- 
sionally arrested during its course and remains stationary for 
some years. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY: 
An individual afflicted with this form of muscular atrophy in which 
the disease has been arrested, is not often capable of doing any 
work and as this condition would not occur until after a long 
period of total disability, an insurance company would not be 
carrying a poHcy on such a person. 

EFFECTS: Individuals having suffered from this disease 
are not insurable for any kind of a policy. 



346 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

SPINAL HYPEREMIA 



SYNONYMS: Spinal congestion; plethora spinalis. 

INFORMATION: Congestion of the spinal cord is a con 
dition which is caused by exposure to cold and dampness, alco- 
hohc excesses, poisons, such as strychnina, picrotoxin, and some- 
times is claimed to be due to injuries of the back. 

SIGNS AND SYMPTOMS: Acute spinal congestion be- 
gins with tingling sensations in the lower limbs and feet, increased 
reflexes with dull pain in the dorsal and lumbar regions, which 
often extends into the hip and thighs. This dull pain is said to 
be increased by the application of heat, but is unaffected by pres- 
sure or movement. Walking is accomplished with difficulty and 
if the upper part of the cord is affected, palpitation of the heart 
and dyspnea are present. Painful priapism and frequent noc- 
turnal emissions occur. 

HOUSE CONFINEMENT: The duration of this affection 
is from a few hours to several days, and house confinement does 
not often last longer than from 2 to 5 or 7 days unless myelitis 
supervenes, when a longer period of house confinement results. 

TOTAL DISABILITY should seldom be over i week for 
individuals suffering with this affection, and if a longer time is 
claimed, it is almost sufficient proof that the diagnosis is incor- 
rect and some other disease is causing the increased length of 
disability. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is not often allowable following a period of total disability 
for this disease, and if demanded, i week should be ample in all 
cases. 

EFFECTS : On account of the difficulty in diagnosis of dis- 
eases affecting the spinal cord and also of the possibility of a re- 
currence of the same disease and compHcations, insurance com- 
panies would seldom issue any kind of a policy to individuals hav- 
ing suffered from any disease or injury to this part of the body. 

MIGRAINE 

SYNONYMS: Hemicrania; megrim; sick, bilious or blind 
headache. 

INFORMATION: Migraine is a paroxysmal pain in the 
head, occurring in persons of nervous temperament and is es- 



1 



ACUTE CEREBRAL LEPTOMENINGITIS 347 

pecially common in women. It is often inherited and may be due 
to menstrual disorders, overwork, eye strain, prolonged mental 
excitement, indigestion and anemia. 

SIGNS AND SYMPTOMS : Attacks of migraine are often 
preceded by restlessness, nervousness, malaise and mental depres- 
sion. The attack proper begins with nausea, vomiting, intoler- 
ance to Hght, inability to perform any mental labor, vertigo and 
sharp "severe pains in the head causing a relaxation of the entire 
body. The pulse is usually soft and slow and the pupils con- 
tracted. This condition persists from a few hours to several days, 
when recovery gradually takes place. 

HOUSE CONFINEMENT lasts from i to 2 or 3 days in 
very severe cases of this affection; mild attacks seldom produce 
any house confinement. 

TOTAL DISABILITY rarely lasts more than from 2 to 4 
days and therefore an individual suffering from an attack of this 
disease is not often entitled to indemnity under a health policy. 
Some few companies pay indemnity for total disability when less 
than a week is lost, but the majority do not pay for disability 
until the individual has been disabled one week and almost all in- 
dustrial companies only pay indemnity from the beginning of 
the second week of disability and require house confinement in 
addition. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is never payable following an attack of this affection. 

EFFECTS : Individuals claiming indemnity for an attack of 
migraine, almost invariably have a history of frequent, previous 
attacks, and if these were not mentioned in the appHcation, an 
insurance company would reject the claim. Individuals suscepti- 
ble to this disease are generally insurable for all kinds of insur- 
ance if the attacks are not of frequent occurrence and do not last 
longer than from one to two or three days. Companies that pay 
indemnity for less than one week of total disability would not 
write health insurance on such a person without a waiver elimi- 
nating indemnity for this affection. 

ACUTE CEREBRAL LEPTOMENINGITIS 

SYNONYMS: Acute meningitis; cerebral fever; arachnitis. 

INFORMATION: Acute leptomeningitis is an acute exu- 
dative inflammation involving the pia mater and arachnoid cov- 
erings of the brain and is caused by acute alcoholism, mental 



348 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

overwork, insomnia, exposure to the sun or other forms of exces- 
sive heat, diseases and injuries of the internal ear and bones of 
the skuH, syphiHs, and sometimes follows blows to the head. It 
may be a complication of typhoid fever, la grippe, erysipelas or 
other infectious diseases and is more common in men in early 
adult hfe. 

SIGNS AND SYMPTOMS: Attacks of this disease may be 
gradual in onset, being preceded by inabiHty to sleep, headache, 
malaise and loss of appetite. When the disease begins suddenly, 
there is a chill followed by irregular high fever, nausea, cerebral 
vomiting, flushed face, photophobia, rapid pulse, severe head- 
ache, delirium and convulsions. The "tache cerebral" is usually 
present in attacks of this disease. As the stage of dehrium be- 
comes less, depression or collapse ensues, when the pulse is irreg- 
ular and slow, the temperature is reduced, involuntary discharge 
of the urine and feces occur and coma supervenes. 

DIFFERENTIAL DIAGNOSIS: Tuberculous Meningitis 
is usually a secondary affection, is most frequent in children and 
the onset is insidious. Tuberculous lesions can generally be de- 
tected involving some other part of the body; the lungs, joints 
or organs of the abdominal cavity being most commionly affected. 

Abscess of the Brain in fifty per cent, of the cases follows mid- 
dle ear disease, but may be caused by injuries to the head which 
have occurred some time previously and is best diagnosed by giv- 
ing attention to the history of the case. For further information 
concerning this, see Abscess of the Brain. 

Delirium Tremens may be mistaken for leptomeningitis and 
is best diagnosed by the eruption which appears in the latter dis- 
ease and is absent in the first and also by the fact that cerebro- 
spinal meningitis is almost invariably epidemic. 

Cerebral Symptoms in TypJioid Fever resemble acute meningi- 
tis, but in typhoid fever there is seen the well known rose spots 
and other symptoms, such as distention of the abdomen, enlarge- 
ment of the spleen, etc., and in this disease there is also obtainable 
the Widal reaction which is usually considered diagnostic of ty- 
phoid fever when it is present and the typical temperature curve 
of the disease. 

HOUSE CONFINEMENT in mild cases of acute cerebral 
leptomeningitis lasts from 2 to 3 weeks; very severe ones require 
confinement to bed and the house for from 4 to 6 or 8 weeks. 

-TOTAL DISABILITY varies according to the severity of 
the disease. Individuals suffering from slight cases of meningitis 



HEMORRHAGIC PACHiYMENINGITIS 349 

due to injuries of the head, are usually totally disabled only 2 to 
3 weeks. If the inflammation is due to another cause, total dis- 
ability may only last from i to 2 or 3 weeks and be followed by 
death, or a slow convalescence may be established and this form 
of disabihty will persist from 4 to 6 and sometimes 10 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment in cases which recover from a severe inflammation can 
usually be claimed for the limit of the policy on account of the 
impaired physical and mental condition as the result of the dis- 
ease. 

EFFECTS : Attacks of leptomeningitis are often fatal. In- 
dividuals having suiTered a slight attack of this disease, are not 
insurable for any kind of a policy until one to two years have 
elapsed and no symptoms of the disease have occurred in that 
time. Severe attacks of meningitis in which recovery is slow, 
render an individual uninsurable for any kind of a policy, until 
two to five years after the illness and a medical report of an ex- 
amination is favorable. When children suffer from this disease 
and fully recover, insurance of any kind can be granted after five 
years have elapsed and the medical examination is satisfactory. 

HEMORRHAGIC PACHYMENINGITIS 

SYNONYMS: Hematoma of the dura mater; pachymenin- 
gitis externa. 

INFORMATION : Hemorrhagic pachymeningitis is a rare 
affection and is an inflammation of the external layer of the dura 
mater and is caused by contusions, fractures, penetrating wounds 
of the skull or secondary to an abscess. When this inflammation 
follows an injury, the period of disability would be covered by 
an accident policy and an insurance company would be liable for 
the payment of indemnity during this time. Should death take 
place within ninety days from the date of accident, the heirs of 
the claimant would probably demand that the face of the policy be 
paid for an accidental death, even though this disease super- 
vened. 

SIGNS AND SYMPTOMS are principally those of cerebral 
pressure following a history and evidence of an injury to the skull 
or abscess formation in which anorexia, insomnia, vertigo, per- 
sistent headache and photophobia occur and are followed by de- 
lirium, convulsions and coma. 



ML AJaL. 



350 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

HOUSE CONFINEAIENT is uncertain, sometimes lasting: 
from I to 3 or 4 days and again from i to 2 or 3 weeks. Death 
generally occurs early in this affection, and house confinement 
lasts from the date of injury — if an accident occurred — to the 
time the fatal termination takes place. 

TOTAL DISABILITY varies and depends on the severity 
of the primary injury. It may only last from i to 3 days and be 
followed by death, or recovery may ensue and this period of dis- 
ability may last from 3 to 6 or 10 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
may be claimed for the limit of the policy following an injury to 
the skull which produces this condition. Such cases, however, 
usually come under an accident poHcy, when partial disability 
would be payable for the length of time the individual was unable 
to properly attend to all his duties and this in the majority of 
cases would not be over 26 weeks or as long as the policy pro- 
vided this form of indemnity. 

EFFECTS : Individuals recovering from a blow to the head 
which produced a hemorrhagic pachymeningitis, would not be 
insurable for any kind of a policy until two to five years had 
elapsed after the date of accident and during which time no un- 
favorable symptoms had appeared. 

ACUTE MYELITIS 

SYNONYMS: Transverse myelitis; general diiTuse mye- 
litis; softening of the spinal cord. 

INFORMATION: Acute myelitis is an acute inflammation 
of the substance of the spinal cord and may be limited to certain 
sections of it. It is caused by exposure to cold, syphilis, rheu- 
matism, lead, mercurial or arsenical poisoning and is sometimes 
the result of injuries to the vertebral column. If this disease fol- 
lows an accident involving the spinal column and the evidence of 
an external injury has been or is apparent, an accident insurance 
policy would cover the period of disability, and if death ensued 
within ninety days from the date of accident, the company would 
probably be liable for the face of the policy. 

SIGNS AND SYMPTOMS : The onset of acute transverse 
myelitis is generally sudden, beginning with a chill, loss of appe- 
tite, coated tongue, constipation, pain in the back radiating into 
the limbs, partial or complete anesthesia of the skin of the limbs 
and moderate fever, the temperature running from 101° to 103° F. 



ACUTE MYELITIS 351 

A characteristic and prominent symptom is the girdle pain 
which is followed by paraplegia and involuntary discharges from 
the bladder and rectum; muscular atrophy, together with bed- 
sores complicate this disease. 

DIFFERENTIAL DIAGNOSIS: Acute Anterior Poliomye- 
litis is more common in children, although it is sometimes seen in 
adults; it is usually of short duration, anesthesia is not present 
and involuntarily discharges from the bladder and rectum do not 
occur. 

Acute Spinal Meningitis is a rare disease and is generally due 
to an infection, although it may be caused by traumatism. It is 
characterized by severe pains, rigidity of the spine, spasmodic 
contraction of the muscles, hyperesthesia of the skin instead of 
anesthesia and absence of girdle pains. 

Hemorrhage Involving the Spinal Cord may be the result of 
an accident or disease. In either case, the symptoms come on 
abruptly with slight paralysis and this becomes worse as the 
hemorrhage increases. 

Hysterical Paraplegia occurs in individuals of an extremely 
nervous temperament. The paralysis appears and disappears fre- 
quently and without cause; nutrition or sensation is not impaired, 
although the latter may be absent in one part of the body and on 
the patient's attention being diverted, it immediately returns. A 
phantom tumor of the abdomen is sometimes present, but disap- 
pears on the administration of an anesthetic. 

HOUSE CONFINEMENT depends on the part of the 
spinal cord involved. In acute ascending or central myelitis, 
death occurs early and house confinement is short, lasting from 
I to 3 or 4 days, sometimes from i to 2 weeks. When the dis- 
ease is not so severe, house confinement may last from 2 to 4 or 6 
weeks, death occurring during this time or recovery taking place 
in some cases. 

TOTAL DISABILITY seldom lasts over 5 to 14 days in 
either acute transverse or central myelitis, as death almost in- 
variably occurs during this time. Should recovery take place, the 
length of total disability is uncertain depending on the site of the 
disease, the extent to which the cord has been involved and the 
resulting spinal irritation and permanent paralysis. These cases 
are often totally disabled from 2 to 4 or 6 months and some- 
times longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy for the period of convalescence, may be- 



352 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

gin at the termination of house confinement and usually persists 
to the limit, — which in practicalh' all policies is never over 26 
weeks. 

EFFECTS : Individuals having suffered from this disease are 
never insurable for any kind of a policy, and if an accident or 
health pohcy is held by such a person it should be cancelled at 
once. 

NEURALGL\ 

SYNONYMS depend on the location of the inflamed nerve. 
Tic-douloureaux, prosopalgia, FothergilFs disease, or trifacial 
neuralgia is an inflammation of the fifth nerve; cervico-occipital 
cervico-brachial, dorso-intercostal and lumbo-abdominal neu- 
ralgia are names which simply indicate the position of the inflam- 
mation. Erythromelalgia or ''red neuralgia" was first described 
by Dr. S. Weir Mitchell and aft'ects the feet. 

INFORMATION: Neuralgia is an inflammation involving 
different nerves of the body, it is more common in adults and fre- 
quently follows exposure to cold and dampness. It may also be 
of reflex origin and is seen in some diseases, such as chronic lead 
poisoning, rheumatism, S3^philis, gout and malaria. Traumatic 
neuralgia, according to Bailey, is rarely seen involving any of the 
cranial nerves, but infrequently injuries of the shoulder and el- 
bow joints result in neuralgic pains. 

SIGNS AND SYMPTOMS : An attack of neuralgia in any 
part of the body usually lasts from a few hours to several days, 
when it disappears and may not return again for weeks or months 
or until exposure causes a recurrence. Severe, lancinating, 
pounding pain is the most prominent symptom of the disease, 
although tenderness over the area supplied by the inflamed nerve, 
sometimes swelling and a pinkish hue to the skin may be present. 
Convulsive twitchings of the muscles controlled by the inflamed 
nerve are occasionally seen. Intercostal neuralgia is frequently 
accompanied by the formation of vesicles over the course of the 
nerve, this being known under the name of herpes zoster. Red 
neuralgia affects the feet and is characterized by intense redness 
and a burning pain of these extrem.ities which is relieved by ele- 
vating them. 

DIFFERENTIAL DIAGNOSIS: Simple Neuritis often 
follows wounds to the nerves, although exposure to cold and 
dampness may be the cause. In this aft'ection the larger nerves 



NEURALGIA 353 

are generally involved with a continuous dull pain, tenderness 
along the course of the nerve, and when the inflammation per- 
sists for any length of time, the peculiar glazed surface, with 
swelling beyond the point of inflammation is present. 

Locomotor Ataxia in the beginning stages may be taken for 
neuralgia, the diagnosis of this affection, however, is soon made 
by the presence of Romberg's symptom, Argyll-Robertson pupil 
and absence of the patellar reflex. 

HOUSE CONFINEMENT is not present in mild or severe 
attacks of this disease when it occurs during the warm months 
of the year. Slight attacks of facial neuralgia cause house con- 
finement of from I to 3 or 4 days during cold weather, while 
severe attacks may confine the claimant within the house from 
I to 2 weeks. Attacks of intercostal neuralgia accompanied by 
herpes, require from i to 2 or 3 weeks of house confinement, this 
time depending on the season of the year and the severity of the 
eruption. 

TOTAL DISABILITY in mild cases occurring in the spring 
and fall in which house confinement has lasted from i to 3 or 4 
days, cause total disability of the same length of time, and indem- 
nity for such a period is not often payable, except by a few com- 
panies whose policy pay for disability when it has not been of a 
week's duration. Severe attacks of this disease during the 
warmer months of the year sometime demand total disability of 
I to 2 weeks. Mild cases affecting the nerves of the face and oc- 
curring during the winter months, may require house confine- 
ment of from 4 to 7 days when total disability must be paid for 
this length of time. Severe cases occurring during cold weather 
and which terminate under the same weather conditions, require 
from I to 3 weeks of total disability, and if the inflammation in- 
volves the intercostal nerves, total disability lasts from 2 to 4 
weeks, when this affection is present during winter weather. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is rarely payable on account of the individual being able to re- 
sume all the duties of the occupation as soon as total disability 
has ended. 

EFFECTS : Infrequent attacks of neuralgia have no bearing 
on the insurability of the individual, but if this disease occurs fre- 
quently and produces disability of one to two or three weeks once 
or twice a year, an insurance company would not issue a health 
policy on such a person unless it contained a waiver eliminating 
indemnity for this affection. Severe cases of trifacial neuralgia 



354 DISEASES OP THE BRAIN AND NERVOUS SYSTEM 

that have persisted for weeks, months and sometimes even years, 
with sHght periods of exacerbations are not insurable for any 
kind of a poHcy, as such cases usually terminate in the removal 
of the gasserian ganglion and as this is a most serious operation, 
no insurance company would care to have a policy on such a 
person. 

NEURASTHENIA 

SYNONYMS: Nervous prostration; nervous exha'ustion; 
spinal irritation. 

INFORMATION: Neurasthenia is a functional disease 
that occurs at all seasons of the year and is more common in men 
than women. It is characterized by a lessened desire or inability 
to accompHsh the various duties of the occupation and results 
from mental overwork, over indulgence in alcohol and tobacco, 
sexual excesses and from various chronic diseases. Insurance 
companies look with much disfavor upon claims arising under 
disability policies for the above disease when the period of dis- 
ability occurs during vacation time and the individual claims he 
is sent by his attending physician to the country to recuperate. 
It is of course possible that this condition might be brought on 
during the summer months, but it is highly improbable and claims 
for disability under these conditions should have the closest in- 
vestigation, and almost invariably it can be proved that the indi- 
vidual is simply taking a vacation and expecting to be paid for it 
by the company with whom insurance is carried. Bailey says 
"the fact that it may develop primarily as the result of injury and 
shock has only been recognized in recent years. When occurring 
in this way, it is called traumatic neurasthenia and differs only 
in slight particulars from neurasthenia due to other causes." 

SIGNS ANEi SYMPTOMS : True cases of neurasthenia are 
preceded with a history of prolonged mental activity with little 
rest or one of the other causes which produce this disease, and 
one of the eadiest symptoms is nervous irritability combined with 
weakness and inability to concentrate the mind for any length of 
time when mental work is attempted. It results in headache, 
restlessness, nervousness, depression, insomnia and a number of 
other vague symptoms attributable to the nervous system. An- 
orexia, constipation, insomnia, change in disposition, pain in the 
back, marked prostration after exercise, tenderness along the 
spinal column, palpitation of the heart, loss of sexual power in 



NEURASTHENIA 355 

the male and painful or suppressed menstruation in the female 
are some of the other symptoms complained of in this disease. 
Loss of weight is always present in true cases of neurasthenia 
and is one of the most important diagnostic points for differen- 
tiating between this disease and hysteria or so-claimed cases of 
neurasthenia. 

DIFFERENTIAL DIAGNOSIS: Hysteria should be dis- 
tinguished from neurasthenia without much trouble. In hysteria 
there is no loss of weight, the individual is subject to various emo- 
tional outbreaks with changeable areas of anesthesia and contrac- 
tures of the muscles. This condition is more frequent in women 
than in men. 

Claims for disability alleging neurasthenia as the cause when 
the disease is not present, are usually made during July and 
August and no history of any condition that would cause neuras- 
thenia is obtainable; the claimant is temporarily out of employ- 
ment, a sojourn in the country is said to have been recommended 
by the attending physician and the individual promptly betakes 
himself into an inaccessible part of the country in the hope that 
the examiner of the company will be unable to reach him. There 
is no loss of appetite or inability to sleep and weight does not 
decrease, but within a short time increases. 

COMPLICATIONS: Neurasthenia is often complicated by 
chronic diseases of the heart, liver, kidneys or lungs and in such 
cases disability is greatly prolonged and the time is generally 
governed by the compHcation and not by the nervous condition. 
When neurasthenia occurs and a diseased condition of some of 
the organs of the body exists in conjunction with it, it is im- 
portant to know when the policy was issued, as all health or dis- 
ability policies do not go into efifect until a certain time after the 
signing of the application and in that application the individual 
warrants that he is in good health. Therefore, if a claim for neur- 
asthenia should arise under a health or disability policy within 
a short time after it was issued and be complicated with a chronic 
disease, such a fact would be sufficient evidence to show that the 
individual was suffering from the chronic disease before the policy 
was written and secured it through fraudulent means; thereby re- 
leasing the company from any liability. 

HOUSE CONFINEMENT does not actually exist in 
claimed cases of this disease in which there is a fraudulent intent. 
Mild cases of neurasthenia require house confinement of from 3 
to 10 days, at the end of which time the individual is ordered into 



I 



356 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

the open air by the attending physician. In severe cases and 
especiahy those in which the "rest cure" is used, house confine- 
ment of from 3 to 6 weeks is necessar)^ and this time is almost in- 
variably spent in bed. 

TOTAL DISABILITY in neurasthenia is very uncertain; 
depending on the individual, the surroundings, the severity of the 
disease, the opportunity for proper treatment and various other 
conditions. Cases in which house confinement has lasted from 
3 to ID days are not often totally disabled more than from 4 to 6 
or 8 weeks. Severe cases in which house confinement has ex- 
isted from 3 to 6 weeks, are usualty totally disabled from 8 to 12 
or 16 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
when provided by the policy, covers the period of disability be- 
ginning from the termination of house confinement to the time 
the occupation is resumed. In such cases, total disability is only 
paid for house confinement and partial indemnity for total disabil- 
ity for the remainder of the time that disability lasts. 

EFFECTS : Individuals having suffered from a mild attack 
of neurasthenia in which disability has persisted from four to eight 
or ten weeks, are not insurable for any kind of a policy until nine 
to twelve months have elapsed after complete recovery and no 
evidence of the return of the disease has shown itself. Severe 
cases of neurasthenia requiring two to three or four months be- 
fore the individual is able to resume work, are not insurable for 
a life or health policy until two to three years have elapsed after 
the date of recovery and good health has existed during that 
time. Accident insurance can usually be written on such indi- 
viduals one year after the termination of disability from neuras- 
thenia. 

NEURITIS 

SYNONYMS : Simple Neuritis. 

INFORMATION : Neuritis is an acute inflammation of the 
nerve trunks and is caused by exposure to cold and dampness, 
traumatism resulting in direct injury to the nerves themselves or 
compression due to swelling or inflammatory products. It may 
also be secondary to certain diseases as syphilis, rheumatism, 
gout or some of the infectious fevers; sometimes it follows lead 
poisoning and excessive use of alcohol. 

SIGNS AND SYMPTO^IS: Acute cases of neuritis which 



NEURITIS 357 

are not due to injury, may begin with a vague feeling of uneasi- 
ness in the parts about to be affected. This is soon followed by a 
burning, tingling pain along the course of the nerve trunk that 
is involved and over this is found tenderness on pressure and 
sometimes slight swelling marks the course of the nerve. Swell- 
ing of the extremity beyond the point of inflammation with glaz- 
ing of the skin and loss of power are also seen in this disease. If 
a neuritis follows an accident, there is a history of such and in 
the majority of cases external evidence of an injury to some part 
of the extremities which may result in this inflammation. When 
this disease arises from such a cause it is usually slow in onset, 
showing itself a few days after the accident has occurred and 
gradually becoming worse until total disability exists in the ex,- 
tremity affected. 

DIFFERENTIAL DIAGNOSIS: Neuralgia is an inflam- 
mation of the smaller nerves and is attended by paroxysmal, 
pounding pain and is sometimes accompanied by herpes. There 
is little if any tenderness over the course of the nerve and loss of 
power does not occur. 

Myalgia involves muscles or groups of muscles and is char- 
acterized by exquisite tenderness over a large surface of skin, 
and on movement sharp, lancinating pain in the affected muscles. 

HOUSE CONFINEMENT depends on the cause of the 
disease, the severity and location. When a shght neuritis occurs 
in the upper extremities, house confinement seldom exists. Se- 
vere cases of neuritis involving the arms causes house confine- 
ment of from I to 3 weeks. Cases involving the lower extremi- 
ties results in house confinement, but this time is variable; from 
3 to 7 days in slight attacks and from 2 to 4 weeks for more pro- 
tracted ones. 

TOTAL DISABILITY in individuals suffering from slight 
attacks of this disease affecting the upper extremity is short and 
sometimes does not exist at all. If the attack has been severe 
and the same parts are involved, total disability lasts from i to 3 
weeks; this time seldom extending beyond the limit of ^louse 
confinement. When the disease occurs in summer, total disabil- 
ity is usually about i week shorter than when cold weather is 
existing. Neuritis involving the nerves of the lower extremity, 
causes total disability of from i to 4 weeks and is shortened or 
lengthened according to the weather conditions at the termina- 
tion of the inflammation. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 



358 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

does not often follow this disease when it appears as a complica- 
tion for some preceding illness, but partial disability often follows 
a period of total disability when the disease has been caused by 
an accident. Sometimes total disability does not exist in cases 
due to traumatism, the individual being partially disabled all the 
time disability exists. In such cases partial disability usually 
lasts from 2 to 4 weeks. Cases of neuritis due to injury which 
are not properly treated by rest from the date of accident, result 
in long periods of partial disability; sometimes from 2 to 4 or 6 
months being necessary before complete use of the extremity is 
regained. 

EFFECTS : Individuals having suffered from an attack of 
neuritis are insurable for any form of policy from two to three 
months after complete recovery, unless the disability has lasted 
from three to six months or more, when an accident or health 
policy would hardly be issued until one year had elapsed without 
any signs or symptoms referable to the disease and a medical ex- 
amination was satisfactory. Even after a long period had elapsed, 
an insurance company would probably place a waiver on a health 
policy eliminating indemnity for disability due to this condition. 

MULTIPLE NEURITIS 

SYNONYMS: Polyneuritis; degenerative, peripheral or 
disseminated neuritis; alcoholic paralysis; pseudo-tabes; beri- 
beri; Kaake. 

INFORMATION: Multiple neuritis is an inflammation of 
a number of nerves and is caused by exposure, alcoholism, rheu- 
matism, syphilis, malaria, metalic poisons and sometimes follows 
some of the acute infectious diseases. It is rarely seen under 
twenty-five years of age and most commonly occurs in persons 
from thirty to fifty years old, women being more frequently at- 
tacked. When this disease occurs endemically as it does in the 
tropics, it is supposed to be caused by a micro-organism. 

SIGNS AND SYMPTOMS may appear suddenly and result 
in death within a short time, but more often evidence of this dis- 
ease develops gradually with loss of appetite, coated tongue, mod- 
erate fever, pain and tingling in the affected limbs, with areas of 
hyperesthesia or anesthesia. The motor phenomena are weak- 
ness in the affected limbs, loss of power, absence of reflexes, with 
atrophy of the muscles and edema of the upper and lower ex- 
tremities. 



OCCUPATION NEUROSIS 359 

DIFFERENTIAL DIAGNOSIS: Locomotor Ataxia is 
sometimes confounded with this disease, but in ataxia there are 
three prominent and diagnostic points; Romberg's symptom, Ar- 
" gyll-Robertson pupil and absence of the patellar reflex. 

Pachymeningitis Interna when suspected shows persistent 
headache, gradual impairment of mental faculties, photophobia 
and later deHrium, convulsions and coma and these are not usually 
present in multiple neuritis. 

HOUSE CONFINEMENT occurs in the acute stages of 
this disease and may last from i to 3 or 5 weeks; at the end of 
which time the individual can generally get around and is per- 
mitted to be in the open air. Such cases become chronic and 
house confinement exists at various times during the course of 
the disease. 

TOTAL DISABILITY is extremely uncertain, sometimes 
lasting from i to 2 weeks when death ensues. In other cases the 
disease becomes chronic and total disability lasts for months or 
years. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, would demand the Hmit of the policy in the majority of 
cases. 

EFFECTS: Individuals suffering with this disease are not 
insurable for any kind of a policy and if they are in possession 
of a health poHcy, an insurance company would endeavor to settle 
the claim at once by allowing a large advance settlement and can- 
celHng as soon as a release was obtained. 

OCCUPATION NEUROSIS 

SYNONYMS: Professional neurosis; artisans', writers', 
dancers', telegraphists', vioHn and piano-players' cramp. 

INFORMATION : An occupation neurosis is an affection 
of the nervous system resulting from constant repeated move- 
ments of certain muscles which finally result in loss of power and 
more or less paralysis in the parts affected. The hands are most 
commonly involved, although sometimes this aft'ection exists in 
the feet. Accident policies do not cover disability due to any of 
the above causes. Total disability exists in the majority of cases. 
although some individuals when affected with this disease quickly 
learn to use the opposite hand, which, however, in a short time, 
frequently becomes similarly affected. 



360 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

SIGNS AND SYMPTOMS are gradual in onset; first begin- 
ning with a stiffening in the parts about to be affected and this 
is followed by a sense of weight and fatigue which becomes so 
great that the extremity is soon useless. In addition there is 
usually pain in the muscles involved, tremors, spasmodic contrac- 
tions and sometimes paralysis. Mental worry and depression are 
associated with the various forms. 

DIFFERENTIAL DIAGNOSIS is not difiQcult when the 
history is obtained, as the affection is usually unilateral in the be- 
ginning and limited to one extremity; generally the one most 
constantly used in the occupation. 

Chronic Lead Poisoning causing paralysis of one of the ex- 
tremities may be mistaken for an occupation neurosis, but in the 
former there is seen the familiar blue line on the gums, a dry 
harsh skin of a sallow or yellowish color and yellowishness of the 
conjunctiva. In addition there is a history of one or more at- 
tacks of lead coHc in practically all cases. 

COMPLICATIONS: Nervous Irritability which may go on 
to depression and melancholia sometimes complicates this affec- 
tion and when it exists, disability is prolonged and the prognosis 
is often unfavorable. 

HOUSE CONFINEMENT is not necessary for persons 
suffering with any form of an occupation neurosis; the individual 
making better progress in the open air and surrounded by friends 
and excitement. 

TOTAL DISABILITY is almost impossible to approximate, 
being extremely uncertain. Some individuals affected with this 
disease in only one hand rapidly learn to use the other, when 
total disability does not last more than from 2 to 3 or 4 weeks, 
unless the other hand becomes affected, when it is again very 
uncertain and if both hands are involved total disabiHty may last 
from I to 2 or 4 months and even longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is sometimes allowable in these cases, but depends altogether on 
the wording of the poHcy. If it provides house confinement for 
total disability, partial indemnity for total disability begins at the 
termination of this period and lasts for a hmited time as pro- 
vided in the poHcy. 

EFFECTS: An individual having suffered disability from 
an occupation neurosis, is not insurable for an accident or health 
policy unless complete recovery has ensued and no signs and 
symptoms have been present for one to two years after the date 



FACIAL PARALYSIS 



361 



of recovery, when- an application would be considered. Life in- 
surance could be written on such a person from six to twelve 
months after recovery has been complete and the individual has 
assumed a new occupation and passed a satisfactory medical ex- 
amination. Insurance companies having claims from such a 
cause are usually willing to settle in advance and pay a reason- 
able figure for a release, provided there is liability on their part. 

FACIAL PARALYSIS 



SYNONYM: Bell's Palsy. 

INFORMATION: Facial paralysis results from pressure 
on the seventh cranial nerve and is an acute condition which may 
be caused by exposure of the side of the face to cold air and 
draughts, middle ear disease, syphiHs, injuries or any condition 
that will produce an exudation along the course of the nerve, 
thus resulting in pressure and paralysis beyond the point of in- 
flammation. It is sometimes a sequelae of rheumatism or the in- 
fectious fevers. 

SIGNS AND SYMP- 
TOMS : The onset of this form 
of paralysis is generally sudr 
den with tingling in the tongue 
and lips and sometimes loss of 
the sense of taste. The side of 
the face involved is motionless 
and without expression, the 
angle of the mouth droops, 
whistHng or smiling is impossi- 
ble, the unaffected muscles pull 
the face to the side opposite to 
that involved in the paralysis, 
with the result that the expres- 
sion is laughable, and any 
movement as talking, smiling, 
etc., makes the individual ap- 
pear grotesque. 

DIFFERENTIAL DIAGNOSIS: Paralysis of this nerve 
due to accidental injuries has a history of such and evidence of 
external injury is apparent, such as swelling and discoloration on 
the same side of the face, the sense of taste is unimpaired and 
the uvula is not afYected by the paralysis. 




FIG. 95.— FACIAL, PARALYSIS. 

Six weeks after injury. Effort to close eye. 

(Harvey Gushing). 



362 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

Exposure to Cold as the cause of this paralysis is often seen 
in individuals who drink to excess and while in such a condition 
exposure results in facial paralysis. These cases have no history 
of an accident, no evidence of any inflammatory product, the 
sense of taste is normal and the uvula is not affected by the pa- 
ralysis. Such claims would probably not be paid by any insur- 
ance company if the facts were known. 

Middle Ear Disease may produce facial paralysis, if so there 
is evidence of a discharge from one or both ears, sometimes pain 
over the mastoid process, the sense of taste is lost or impaired 
and paralysis of the uvula exists, causing it to hang in an oblique 
position. 

Pressure Within the Skull may result in Bell's palsy, but 
usuall}^ when this is the cause, other portions of the body are 
affected and paralysis of the muscles of the face is only partial, 
the upper part not often being involved. Cerebral symptoms are 
always present when pressure is within the brain. 

COMPLICATIONS: Eacial Paralysis frequently exists as 
a compHcation to some other acute disease, and in such cases, 
disability is prolonged by the complication. 

HOUSE CONFINEMENT is, not often necessary in un- 
compHcated cases of Bell's palsy,* unless the paralysis exists dur- 
ing the winter months when 3 to 7 days of house confinement 
may be required. Individuals whose occupation demands con- 
stant talking, often remain in the house from i to 2 or 3 weeks, 
but this is generally due to pride and while an insurance company 
does not contemplate paying for loss of time for such a reason, 
yet it is seldom that indemnity will be refused when these con- 
ditions exist. 

TOTAL DISABILITY is only deserved in the class of risks 
who use the voice in the occupation, such as singers, pubhc speak- 
ers, etc., when i to 2 weeks are usually sufficient. Claims for 
total disability when the cause is alleged to be due to cold, should 
be most closely investigated, as most of these are due to exposure 
following over indulgence in alcoholic liquor. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is rarely deserved by any class and certainly is not payable 
when total disability has been allowed for a period of house con- 
finement. If the paralysis follows an injury, partial disability also 
is not allowable, except in persons whose occupation demands 
almost continuous use of the voice. 



SCIATIA 363 

EFFECTS : Individuals having suffered from facial paralysis 
in which the cause has been traumatism or exposure, are insur- 
able as soon as the condition disappears, — provided the moral 
hazard is good. When the paralysis is due to middle ear disease 
or pressure within the skull, such persons are not insurable for 
any kind of a policy until some time after the cause of the pa- 
ralysis has disappeared; and in the case of middle ear disease, they 
are not insurable for a life or health policy until three to five 
years have elapsed after complete cessation of the aural discharge. 
Accident insurance w^ould be issued by some companies as soon 
as the muscles on the affected side regain their normal tone, irre- 
spective of any existing ear disease. 

SCIATICA 

SYNONYMS: Sciatic rheumatism; neuralgia of the sciatic 
nerve; hip-gout. 

INFORMATION: Sciatica is an acute or chronic inflam- 
mation of the sciatic nerve which generally shows itself in indi- 
viduals troubled with rheumatism or gout and after exposure to 
cold and dampness has occurred. It is also present in those suf- 
fering with syphilis and metalic poisoning and follows accidents 
to the hip or thigh in which the injury involved this nerve. 

SIGNS AND SYMPTOMS : The onset of an attack of sci- 
atica may be sudden or gradual, commencing with tingling along 
the course of the nerve and numbness in the extremity. The 
tingling soon becomes a sharp, severe, lancinating pain which 
occurs in paroxysms lasting various lengths of time and extend- 
ing down the thigh into the leg, foot and toes. This pain is in- 
creased on the slightest movement and tenderness exists along 
the course of the nerve, but sometimes only in spots. 

DIFFERENTIAL DIAGNOSIS: Coxalgia is characterized 
by pain inside the hip joint and this is made worse by pressure 
over the great trochanter. It is also referred to the inner sur- 
face of the knee joint and pressure over the course of the sciatic 
nerve fails to elicit any tenderness which would be the case in 
sciatica. 

COMPLICATIONS: Sciatica often exists as a complica- 
tion of some other disease, and when found the disability result- 
ing from the primary disease is lengthened according to the time 
required for this complication. 

HOUSE CONFINEMENT lasts from t to 2 weeks in the 



, .j,^ i J ; y^v ' 



364 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

average case of inflammation of this nerve and this time may be 
prolonged from 2 to 7 days when the termination of this disease 
occurs during damp, wet weather. Severe cases require from 
2 to 4 or 6 weeks of house confinement. 

TOTAL DISABILITY in mild cases lasts from i to 3 weeks; 
the usual time, however, being 2 weeks. Sciatica sometimes be- 
comes subacute or chronic, in which event total disability may 
last from 2 to 4 months. When the termination of the disease 
occurs during the winter months, the above time in acute cases 
may be prolonged 2 to 7 days. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is sometimes allowable. When sciatica occurs during the 
summer months, from 2 to 4 or 6 weeks may be necessary, but 
the period for which full indemnity is paid for total disability is 
shortened. 

EFFECTS: Individuals having suffered from an attack of I 
sciatica are insurable for any kind of a policy from four to six ■ 
months after complete recovery, but good underwriting would 
demand a waiver eHminating indemnity for this disease under a 
health or disability policy to any one having suffered from one or 
more attacks. 

SPINAL MENINGITIS 

SYNONYM: Leptomeningitis spinalis. 

INFORMATION : Spinal meningitis is an inflammation of 
the membrane covering the spinal cord and results from infection 
from tubercle bacilH, syphilis, traumatism, typhoid fever or sep- 
ticemia. It is a rare disease and is usually described as being 
acute or chronic. 

SIGNS AND SYMPTOMS in the acute form come on grad- 
ually with a boring pain in the back which is made worse by 
movement and which follows the course of the spinal nerves caus- 
ing a sensation of constriction around the body, rigidity of the 
spine, tenderness, and when the exudation is sufficient, slight an- 
esthesia or paralysis of the limbs is present if the pressure is in 
the lumbar region; when above, interference with the heart and 
respirations is seen. Inability to extend the flexed leg — Kering's 
sign — with fever, chills and prostration are always present. 

DIFFERENTIAL DIAGNOSIS : Myelitis is generally sud- 
den in onset, the pain is of less intensity, paralysis occurs earlier 



SUNSTROKE 365 

and is more complete, bed-sores are common and involuntary 
discharges from the bladder and rectum follow. 

Tetanus always has a history of a wound inflicted one to two 
or three weeks before signs and symptoms of this disease mani- 
fest themselves; fever is absent, the muscles of the jaw are early 
involved and marked tenderness does not exist over the spinal 
column. 

COMPLICATIONS: Cerebrospinal Meningitis almost al- 
ways occurs in conjunction with this disease and the length of 
disability is according to the time required for recovery from the 
former disease. 

HOUSE CONFINEMENT: Spinal meningitis almost in- 
variably ends in death and house confinement commences with 
the illness and continues until a fatal termination takes place. 
The few cases which do recover have long periods of house con- 
finement, from I to 3 or 4 months often being necessary, and 
this is especially true if the disease occurs during the fall, when 
the individual is confined in the house until warm weather re- 
turns. 

TOTAL DISABILITY may last from i to 3 weeks, but 
usually death ensues about 10 days after the commencement of 
the disease. When recovery takes place, total disability lasts 
from I to 2 or 4 months and sometimes longer; the time depend- 
ing on the rapidity with which the inflammatory products which 
produce the paralysis are absorbed. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
may be payable if the policy provides such a contingency on the 
termination of house confinement. Such cases generally run the 
limit of the policy. If this disease follows an injury, partial dis- 
ability is also, usually payable for the full time allowed by the 
policy. 

EFFECTS: Adults having suft'ered from spinal meningitis 
are never insurable for any form of policy. If the inflammation 
occurs during childhood and all effects have disappeared, such 
a person would be insurable for all forms of insurance when adult 
life was reached, — if the medical examination was satisfactory. 

SUN STROKE 

SYNONYMS: Thermic fever; heat stroke; heat exhaus- 
tion; insolation; siriasis; coup-de-soleil. 

INFORMATION: Thermic fever follows exposure to ex- 



366 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

cessive high temperature; either the sun's rays or artificial heat. 
It is more frequent in summer than winter and occurs more 
often when the body is fatigued or debiUtated by excesses of any 
kind. Accident insurance pohcies pay a specific sum according 
to the company writing the insurance for death from sun stroke, 
if it. occurs independent of all other cases and within ninety days 
from exposure. Such policies, however, do not often pay weekly 
indemnity and therefore when sun stroke occurs and disability 
follows, weekly indemnity is not payable unless the individual 
carries a general disability policy. 

SIGNS AND SYMPTOMS depend on the nature of the 
exposure. 

Sun Stroke develops suddenly and is often preceded by nau- 
sea, headache, vertigo and a sense of exhaustion. Unconscious- 
ness appears early, the face is flushed and hot, the eyes injected, 
the pulse is rapid, respirations are quick and shallow and the tem- 
perature is high, ranging from io6° to iio° F. 

Heat Exhaustion also develops rapidly, sometimes being pre- 
ceded by a sense of weakness which is followed by prostration, 
the face is pale and cool, the skin moist, respirations increased, 
pulse rapid and feeble and the temperature subnormal, sometimes 
as low as 95° to 96° F. Complete relaxation of the muscles, with 
partial or complete unconsciousness and sometimes tremors or 
convulsions are present. 

DIFFERENTIAL DIAGNOSIS: Coma due to injuries, al- 
cohol, uremia and other causes may be mistaken for unconscious- 
ness due to sun stroke, and these forms have all been described 
under Apoplexy. Usually the history and season of the year, 
however, will serve to make the proper diagnosis in cases of sun 
stroke. 

SEQUELAE almost invariably follow cases of sun stroke. 

Persistent Headache or Vertigo may supervene and be present 
to a more or less marked degree during the warm months of the 
year or whenever the individual is exposed to a temperature of 
80° F or over. 

Epilepsy, Impaired Mental Activity or Insanity often follows 
cases of sun stroke, becoming permanent or persisting for a vari- 
able time. 

Sensitiveness to high temperatures almost invariably results 
from sun stroke and lasts for several years or more. In such 
cases during the hot months of the year, much inconvenience and 



TETANUS 367 

vague symptoms are complained of by persons having suffered 
from sun stroke. 

HOUSE CONFINEA/[ENT: Sun Stroke cases are treated 
in the open air whenever possible, and house confinement under 
these circumstances means the time spent in bed and this is 
usually from i to 2 weeks when recovery follows this exposure. 
Many cases of sun stroke succumb within 24 to 48 hours. 

Heat Exhaustion generally requires from i to 3 weeks con- 
finement to bed and the house; this time depending on the se- 
verity of the exhaustion present on account of the exposure to 
high artificial heat. 

TOTAL DISABILITY in cases of sun stroke or heat ex- 
haustion which are not followed by death, lasts from i to 3 
weeks; the average time, however, being about 10 days. Severe 
cases of sun stroke sometimes require from 3 to 6 weeks of total 
disability and this is especially true if the occupation of the indi- 
vidual affected requires much mental activity. Complications 
prolong the above periods of disability. 

PARTIAL INDEMNITY EOR TOTAL DISABILITY 
if allowed by the poHcy is rarely payable in addition to the above 
time. 

EFFECTS : Young adults having suffered an attack of sun 
stroke or heat exhaustion, are generally insurable for all kinds 
of insurance from one to two years after the date of exposure. 
Individuals over forty years of age would hardly be considered 
insurable for a life or health policy until at least two to five years 
had passed after the date of the sun stroke or heat exhaustion. 
An accident poHcy, however, could be written one year after the 
date of exposure unless some complication was present, such as 
attacks of vertigo, epilepsy, etc. 

TETANUS 

SYNONYMS: Lock-jaw; trismus; cephahc tetanus. 

INFORMATION: Tetanus is an acute infectious disease 
due to a specific bacillus, — the bacillus of tetanus, — which gains 
entrance to the circulation through an abrasion or opening of 
some kind in the skin, and almost invariably this opening has 
been produced accidentally and a history of an accident is obtain- 
able. Therefore, disability caused by this disease is usually con- 
sidered as being covered by an accident policy and insurance com- 
panies generally pay these claims when presented. If an indi- 



^W 



368 DISEASES OF THE BRAIN AND NERVOUS SYSTEM 

vidual is carrying an accident and general health policy, it of 
course would make no difference as to the manner in which the 
disease was contracted as far as weekly indemnity w^as concerned, 
for the reason that if the accident policy did not cover the dis- 
ability, the general health policy would do so and the company 
would be liable for the resulting weekly indemnity. Should death 
occur, however, it would be highly important to know the man- 
ner in which the disease was contracted. If accidental in origin, 
the company would probably be liable for an accidental death — | 
provided it occurred within ninety days — and if not accidental in ■ 
origin, no death indemnity would be payable by the company. 
Tetanus is more common in warm climates and in men than in 
women and generally occurs between ages of ten and forty years. 

SIGNS AND SYMPTOMS: 
An attack of tetanus begins from 
a a few days to three or four weeks 

after the bacilli gain entrance. 
There first appears a stiffening in 
the muscles of the neck and 
lower jaw and this gradually ex- 
tends and involves those in the 
back, abdomen and lower extrem- 
ities. Swallowing is difficult, ex- 
treme hyperesthesia exists and 
spasms of the muscles occur and 
are accompanied by intense pain. 
The lower jaw is tightly closed 
against the upper and opistho- 
tonos is present. 
DIFFERENTIAL DIAGNOSIS : Strychnine Poisoning 
takes effect suddenly or gradually. If the former, sudden con- 
tractions of the muscles may throw the body several feet, when it 
becomes rigid and remains in this position for a short time, when 
relaxation takes place. If the onset is gradual, there is no his- 
tory of a wound and usually there can be obtained a history of 
swallowing the poisoning intentionally or accidentally. The mus- 
cles of respiration are more affected in strychnine poisoning and 
the convulsions are tonic in character, but with usually short 
periods of relaxation between the spasms and these periods of 
quiet do not occur in tetanus. 

Hydrophobia is characterized by a respiratory spasm which 
is excited by attempts at swallov/ing; mental symptoms are evi- 





^•^:^-' 


Fig-. 96.- 
(Frankel 


—Bacillus of Tetanus X 1000 
and Pfeiffer). 



TETANUS 369 

dent and trismus does not exist. Hydrophobia not only has a 
history of an injury, but almost invariably scars from the bite are 
found on examination. 

HOUSE CONFINEMENT begins when the disease shows 
itself and ends at the time of recovery or a fatal termination oc- 
curs and this latter seldom requires over 5 to 10 days. Cases 
which go on to recovery are confined in the house from 2 to 4 
weeks; this time depending on the severity of the attack. 

TOTAL DISABILITY in the majority of cases is short and 
lasts only during the time required for house confinement, which 
is from 3 to 10 days in the majority of cases. Individuals who re- 
cover from tetanus are totally disabled from 3 to 5 weeks or 
more. If the skull is trephined, total disability is increased from 
3 to 4 weeks from the date of operation. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY: 
As this disease is usually accidental in origin, partial disability is 
payable after the termination of total disability and lasts from 
2 to 4 weeks in cases which recover without an operation. If 
this is performed, partial disability — following an increased period 
of total — lasts from 3 to 6 or 8 wxeks, depending on the result 
of the operation and the duties of the occupation. 

EFFECTS: Individuals having suffered from an attack of 
lock-jaw in which recovery takes place without any complica- 
tion or operation, are insurable for all kinds of insurance from 
four to six months after the date of complete recovery. If an 
operation has been necessary and recovery has been complete, 
insurance of all kinds can be issued from nine to twelve months 
after the date of operation. 



24 



CHAPTER XIV 

DISEASES OF THE CIRCULATORY SYSTEM 

ANEMIA 

• SYNONYM: Spanemia. 

INFORMATION: Anemia is described as a deterioration 
of the blood, with altered relations of the fluid and soHd parts 
(Stengel) and is more common in the female sex. It may be due 
to overwork — either mental or physical — squalid surroundings, 
prolonged and excessive nursing, cancer, Bright's disease, syphi- 
lis, malaria or chronic intestinal diseases. 

SIGNS AND SYMPTOMS are pallor of the skin and gums, 
loss of appetite, poor digestion, muscular weakness, increased 
respirations, rapid pulse with often a hemic murmur, headache, 
vertigo and fainting, together with lack of desire for mental or 
physical work. 

DIFFERENTIAL DIAGNOSIS: Anemia is not often hard 
to differentiate. It frequently occurs as a complication to other 
diseases and in such cases, the period of disability is controlled by 
the more serious illness or prolonged by the complication. 

Leucocythemia resembles anemia in the general symptoms, 
but in this disease the number of white cells is enormously in- 
creased, sometimes reaching as high as five hundred thousand in 
a cubic millimetre. 

HOUSE CONF^'INEMENT does not exist in the early 
stages and when present indicates that the disease has been exist- 
ing for some time. For how long, however, that this condition 
has been present it is impossible to predicate. House confine- 
ment may exist during the winter months and last from 3 to 6 
weeks or longer; depending on the termination of the disease, 
either by recovery or death. If the latter, from 10 to 20 weeks 
may be necessary before this takes place. 

TOTAL DISABILITY lasts from 2 to 4 weeks in cases of 
anemia that have been going on for some time or until total dis- 
ability ensues, when by proper treatment, rest, etc., this length of 
time is usually sufficient for the individual to have recovered 

371 



372 DISEASES OF THE CIRCULATORY SYSTEM 

enough to return to some of the duties of his occupation. When 
the case goes on to a fatal termination, from lo to 20 weeks or 
more may be required before death occurs. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
may be payable if the policy provides this form of indemnity after 
the termination of house confinement. In such cases, this may 
last from 2 to 6 weeks. 

EFFECTS : Individuals with a history of having suffered 
with anemia, are considered doubtful risks by insurance com- 
panies and therefore are seldom insurable for any form of a policy 
unless the disease has occurred a number of years previously and 
from five to ten years have elapsed without any symptoms re- 
ferable to it. In such cases an application for different forms 
of insurance when accompanied by the report of a medical ex- 
amination would be considered. 



ANGINA PECTORIS 

SYNONYMS: Neuralgia of the heart; stenocardia; breast 
pang. 

INFORMATION : Angina pectoris is a paroxysmal disease 
characterized by sharp pains in the region of the heart which 
sometimes extend into the left shoulder and arm. It is much 
more frequent in men than in women and is more common after 
middle life, being due to any condition which causes hardening of 
the coronary arteries. 

SIGNS AND SYMPTOMS : The attack comes on suddenly 
during the early morning hours, when there is severe pain over 
the heart with a sense of constriction about the bod}^, increased 
respirations, feeble pulse, rigidity of the body, great anxiety for 
fear of approaching death; the face is pale with a cold perspira- 
tion on the forehead and breathing is difficult. These attacks 
last from a few seconds to several minutes, when death occurs 
or recovery takes place and another attack is not suffered for 
some weeks or months and during this time there is an entire 
absence of symptoms. 

DIFFERENTIAL DIAGNOSIS: Pseudo-Anginal attacks 
occur almost invariably in women of nervous temperament and 
commence gradually with emotional outbreaks, such as laughing 
and crying, distention of the abdomen, diffused precordial pain 
and the usual symptoms of hysteria. These pseudo attacks last 



4 



ACUTE ENDOCARDITIS 373 

longer than true anginal attacks and there is no evidence of any 
organic disease of the heart or arteries. 

COMPLICATIONS: Brighfs disease, Syphilis, Rheuma- 
tism, Gout and other chronic diseases often complicate attacks of 
angina and perhaps have something to do in causing this condi- 
tion. When any of these complications are present and disabiHty 
occurs, it is caused by the complication and not by the attack of 
angina. 

HOUSE CONFINEMENT: On account of the short du- 
ration of attacks of angina pectoris, house confinement is not 
necessary, but individuals sometime remain in the house for sev- 
eral days to recuperate and in the fear that another attack may 
occur. 

TOTAL DISABILITY should not be paid on claims which 
give as the cause, attacks of this disease, unless the policy pays 
for less than one week of total disability when i or 2 days may 
sometimes be required. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is not allowable in any case. 

EFFECTS : Individuals having suffered from attacks of an- 
gina are not insurable for a life policy, unless the disease has not 
shown itself for five to ten years or more and the individual is 
under forty years of age. If over this age and with the above 
history, fife insurance would not be considered, but accident or 
health insurance might be written at any time with a waiver on 
the health policy eliminating indemnity for disability from this 
cause. 

ACUTE ENDOCARDITIS 

SYNONYMS: Exudative endocarditis; valvulitis. 

INFORMATION: Acute endocarditis is an inflammation 
of the hning membrane of the heart. It is usually confined to the 
valves and almost invariably follows some of the acute diseases, 
such as acute articular rheumatism, acute Bright's disease, pleu- 
risy and the infectious diseases, as diphtheria, scarlet fever, pneu- 
monia, etc. 

SIGNS AND SYMPTOMS of acute simple endocarditis are 
usually not well marked, there is mild dyspnea, precordial pain, 
increased pulse rate and some fever. These cases are generally 
not diagnosed until auscultation shows a slight murnun- of the 
heart. 



374 



DISEASES OF THE CIRCULATORY SYSTEM 



Acute Ulcerative Endocarditis occurs more often in the course 
of another disease and shows itself by an increased, irregular tem- 
perature, pain over the region of the heart with a rapid and irreg- 
ular pulse, palpitation, shortness of breath and sometimes nausea 
and vomiting. Auscultation shows a murmur which is variable 
in intensity. 

DIFFERENTIAL DIAGNOSIS: Pericarditis may show 
swelling in the precordial region with dullness. There is a fric- 
tion sound between the heart and the pericardium which occurs 




1 



Fi§-. 9 7. — Acute ulcerative endocarditis, 
of Pathology). 



(American Text-Book 



with either cardiac sound and is influenced by pressure, while the 
murmur in endocarditis is fixed and uninfluenced by pressure and 
is transmitted in some cases to distant points. 

COMPLICATIONS: Embolism may follow this disease, 
when the signs and symptoms will depend on the part of the body 
afifected. If the embolus lodges in the peripheral vessels, a pete- 
chial rash may result with pain and tenderness; if in the brain, un- 
consciousness or paralysis may supervene; if in the kidneys, al- 
buminuria mav follow. 



DIL.ITATION OF THE HEART 375 

HOUSE CONFINEMENT lasts from i to 2 or 3 weeks if 
this disease occurs alone. When it exists as a complication to 
other diseases, the duration of the primary illness is prolonged 
from 2 to 3 or 4 weeks according to the severity of the endo- 
carditis. 

TOTAL DISABILITY in uncomplicated cases lasts from 
2 to 4 weeks; this time depending on the severity of the inflam- 
mation and the occupation of the individual. If the duties are 
inside and can be performed with practically no manual labor, 
the length of total disabiUty is shorter than if the disease occurred 
in some one requiring much physical exertion in the perform- 
ance of the daily labor. When acute endocarditis exists in con- 
junction with a previous illness, total disability is increased in 
the average cases from i to 3 weeks. If an attack of severe acute 
articular rheumatism is followed by an inflammation of the lining 
membranes of the heart and the individual is already greatly 
debilitated, total disabihty is prolonged in such and similar cases 
following other diseases, from 4 to 6 or 8 weeks from the onset 
of the heart compHcation. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment may be necessary and lasts from 2 to 4 or 6 weeks; this 
time, however, depending on the severity of the primary illness 
and also of the endocarditis. 

EFFECTS : Attacks of endocarditis almost invariably leave 
an impaired heart which is- manifested by a murmur of more or 
less intensity, consequently, such individuals are never insurable 
for an accident or health policy, and a substandard life policy only 
can be granted them. 

DILITATION OF THE HEART 

SYNONYMS: Enlargement of the heart; hypertrophy. 

INFORMATION : Dilitation of the heart is an increase in 
its size, either due to the enlargement without hypertrophy of 
the muscle or enlargement in which the muscle participates. Dili- 
tation of the heart is seen in conjunction with certain diseases, 
such as syphilis, chronic bronchitis, rheumatism, gout, chronic 
valvular disease and Bright's disease. Acute dilitation may re- 
sult from over exertion, but in such cases almost invariably the 
heart muscle has been previously diseased and on a sudden strain- 
ing, acute enlargement without hypertrophy occurs. 



I 



376 DISEASES OF THE CIRCULATORY SYSTEM 

SIGNS AND SYMPTOMS: The pulse is rapid, feeble and 
often irregular or intermittent; there is cough, dyspnea, head- 
ache, dizziness and vertigo. On palpation the impulse is marked 
and diffused, the apex beat is displaced downward and outward 
and on auscultation, the sounds are weak and are often accom- 
panied by murmurs of varying degrees of intensity. When the 
dihtation results from over exertion, weakness is an early symp- 
tom and usually causes disability at once, while if the condition 
has been gradually coming on, there is a history of more or less 
loss of time from labor extending over weeks or months until it 
finally terminates in disability. 




Fig. 98. — Hypertrophy of the left ventricle. (Stengel). 

DIFFERENTIAL DIAGNOSIS: Hypertrophy is differen- 
tiated from dilitation of the heart by the character of the pulse, — 
strong, regular and full, and by auscultation and percussion which 
shows the heart enlarged with a strong impulse, the heart sounds 
being normal in every respect. 

Pericardial Effusion appears suddenly, but almost invariably 
in conjunction with some acute disease. When this condition 
exists, the heart sounds are feeble on account of being masked by 
fluid in the pericardial sac. Dullness which is well marked over 
the distended pericardium is ascertained by percussion; this area 
is triangular in form with the apex above and the base below. 
Absence of the apex beat from its usual position is noticed. 



LEUCOCYTHEMIA • 377 

COMPLICATIONS: Dilitation of the heart may occur as 
a compHcation of some acute infectious disease and if such a con- 
dition ensues, disability is prolonged according to the character 
of the previous disease, the physical condition of the individual 
and the extent of the dilitation. 

HOUSE CONFINEMENT in cases of acute dilitation fol- 
lowing over-exertion is uncertain, depending on the amount of 
strain sustained by the heart, the physical condition of the per- 
son, the rapidity with which recuperative changes take place and 
the amount of enlargement present. These cases usually, how- 
ever, require from 2 to 4 or 6 weeks of house confinement, the 
greater part of this time being spent in the recumbent position. 
If this condition follows any acute disease, house confinement is 
prolonged from i to 3 or 4 weeks; this time depending on a num- 
ber of conditions. 

TOTAL DISABILITY follows in cases of acute dilitation 
of the heart, and in preferred risks lasts from 2 to 3 or 4 weeks. 
Ordinary risks who are already in poor physical condition, re- 
quire from 3 to 6 or 8 weeks and sometimes longer before being 
able to resume a part of the occupation. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, lasts from i to 3 or 4 weeks in preferred risks, and from 
2 to 4 or 6 weeks in ordinary ones. 

EFFECTS : Individuals with a history of having suffered 
with dilitation of the heart either from over-exertion or in con- 
junction with any disease, are not insurable for any kind of a 
policy unless the condition occurred in early childhood and the 
heart had become normal by the time adult life was reached. 
Accident insurance companies usually cancel accident or health 
policies whenever they receive a claim for disability from dilita- 
tion of the heart or secure information that such a condition 
exists. 

LEUCOCYTHEMIA 

SYNONYMS: Leucocythemia: leucemia: leukemia: anemia 
splenica; white blood; white cell blood. 

INFORMATION : Leucemia is an impoverished condition 
of the blood in which there is an enormous increase in the white 
corpuscles, with enlargement of the liver, spleen and lymphatic 
glands and change in the bone marrow. The disease is more fre- 



rs-S5^ 



378 DISEASES OF THE CIRCULATORY SYSTEM 

quent in middle life, affects males more often than females and 
is said to be hereditary and in some cases follows pregnancy, 
syphilis, malaria and traumatism. 

SIGNS AND SYMPTOMS: The onset of this disease is 
gradual and resembles anemia. There may be moderate fever 
with impairment of vision and later on the liver and spleen be- 
come enlarged and hemorrhages occur into the mucous mem- 
branes and under the skin, which is pale and waxy in appearance. 
The blood consists of little coloring matter and a greatly in- 
creased number of white blood cells which are of various shapes. 
The above signs and symptoms usually persist for one to three 
years, but sometimes the condition is an acute one and the last 
stages are reached within two to three months. 

DIFFERENTIAL DIAGNOSIS: Anemia resembles leu- 
cemia in the early stages, but the differential diagnosis is easily 
made when the microscope is used. 

COMPLICATIONS: This disease may exist with and com- 
pHcate tuberculous diseases of the lungs or other parts of the 
body. 

HOUSE CONFINEMENT does not exist in this disease 
until near the termination, when the individual becomes so weak 
that confinement to bed is obHgatory and in such cases the time 
is uncertain, sometimes lasting a few weeks only, other times 
from 2 to 4 or 6 months. 

TOTAL DISABILITY does not occur until late in the dis- 
ease, but begins before house confinement is necessary and per- 
sists to the termination of the case. In acute cases, total disabil- 
ity may only last from i to 2 or 3 months when a fatal termina- 
tion ensues. More chronic cases require total disability which 
lasts a variable time; in some cases from i to 2 or 3 months, while 
in others from 3 to 6 or 9 months may be necessary. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if provided by the poHcy after the termination of house confin- 
ment, is rarely necessary as almost invariably these cases are ter- 
minated by death. 

EFFECTS: Individuals suffering with this disease are not 
insurable for any kind of a policy and if the condition is known to 
an insurance company, the policy would be cancelled at once. 
Claims arising under this disease in which the policy has not 
been in force more than three to six months should be closely 
investigated, as it is almost a foregone conclusion that the con- 



ACUTE AND CHRONIC MYOCARDITIS 379 

dition was present when the poHcy was taken out, although it 
might not have been known to the appHcant. 

ACUTE MYOCARDITIS 

SYNONYMS: Carditis; abscess of the heart. 

INFORMATION: Acute myocarditis is an acute inflam- 
mation of the heart muscle. It follows or complicates acute in- 
fectious diseases or results from an attack of endocarditis or peri- 
carditis. 

SIGNS AND SYMPTOMS of this disease are very obscure 
and sometimes the diagnosis is not made until after death. In 
some cases there is pain, dyspnea, feeble, rapid and irregular 
pulse; the apex beat and heart sounds are weak and evidence of 
edema is seen in the later stages. 

HOUSE CONFINEMENT in this disease rarely lasts over 
2 to 3 or 5 days when death terminates the case. Should this not 
occur, chronic myocarditis may supervene, when disability is pro- 
longed. 

TOTAL DISABILITY is short and seldom lasts over i 
week unless the condition becomes chronic, when this form of 
disabiHty is uncertain. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the. policy after the termination of house confine- 
ment, would be necessary in cases which become chronic. 

EFFECTS : Should the individual recover, an impaired risk 
results and life insurance would not be issued except under a 
substandard policy. Accident or health insurance might be writ- 
ten one to two years after full recovery has taken place, provided 
the individual is shown by a medical examination to be an average 
risk. 

CHRONIC MYOCARDITIS 

SYNONYMS: Chronic carditis; chronic interstitial myo- 
carditis; fibroid heart; fibrous myocarditis; cardio-sclerosis. 

INFORMATION : Chronic myocarditis sometimes results 
from an attack of myocarditis, but usually this is a chronic in- 
flammation and develops gradually; the heart muscle deteriorat- 
ing by fatty degeneration or fatty infiltration accompanied by 
fibroid induration. It is said to be most frequently caused by 
sclerosis of the coronarv arteries; other causes are excessive use 



380 DISEASES OF THE CIRCULATORY SYSTEM 

of tobacco or alcohol, syphilis, chronic diseases of the kidneys or 
other parts of the body. The disease is most common in those 
past fifty years of age and should not occasion a claim under an 
accident or health polic}^, — unless the policy has been in exist- 
ence several years or more. 

SIGNS AND SYMPTOMS are not marked unless an act of 
over-exertion causes symptoms referable to a weakened heart, 
when there is shortness of breath, cardiac palpation, irregular, 
intermittent pulse with headache and faintness. Percussion 
shows that the heart is somewhat enlarged and on auscultation 
the sounds are found to be weak and muffled with murmurs and 
accentuation of the second sound in some cases. 

HOUSE CONFINEMENT is not necessary in those suf- 
fering from a chronic inflammation of the heart muscle, unless 
some act of over-exertion causes a temporary period of disability, 
when the individual may be confined to the house and bed until 
the organ becomes rested and regains part of its impaired tone. 
This time does not usually last more than i to 2 weeks. 

TOTAL DISABILITY is not present in those suffering 
with chronic myocarditis until house confinement is made neces- 
sary on account of some indiscretion, when this form of disability 
lasts from i to 2 or 3 weeks; at the end of which time the indi- 
vidual is generally able to resume the duties of his occupation. 

PARTIAL INDEMNITY EOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is sometimes necessary in these cases, but usually not more 
than I week is demanded. 

EFEECTS: Individuals suffering with this disease are not 
insurable for any kind of a policy if the condition is known. In 
some cases it is impossible to tell by a medical examination that 
such a condition exists and this is especially true when the indi- 
vidual endeavors to withhold all information. Those suffering 
with this disease are extremely poor risks for accident insurance, 
for the reason that a sudden death is liable to occur at any mo- 
ment, and if this should happen while the policy holder was in 
front of a vehicle of any description and was run down, a claim 
for an accidental death would be the result and could not be dis- 
proved without a postmortem examination, which of course the 
insurance company could demand and secure. Even though a 
death under such circumstances was entirely due to the condition 
of the heart, an insurance company would have more or less 
trouble in disproving the claim. 



PERICARDITIS 381 

PERICARDITIS 

SYNONYMS: Acute pericarditis; chronic pericarditis; ad- 
hesive pericarditis. 

INFORMATION: Pericarditis begins as an acute inflam- 
mation of the pericardium and when recovery does not follow 
within a reasonable time, chronic pericarditis results. This in- 
flammation follows or is combined with rheumatism, gout, septi- 



'"^.. 





Pig. 99. — Acute pericarditis. (Bramwell). 

cemia, tuberculosis, scarlet fever, smallpox, diabetes or Bright's 
disease and rarely is due to exposure or injurv. 

SIGNS AND SYMPTOMS: An attack of this disease often 
comes on insidiously when a long illness is causing disability and 
unless for some reason, some special signs or symptoms call at- 
tention to the heart, the onset is not noticed. Acute pericarditis 



382 DISEASES OF THE CIRCULATORY SYSTEM 

usually begins with nausea, vomiting, chills, pain over the region 
of the heart which is increased by pressure, cough without ex- 
pectoration, increased pulse and irregular fever. In the early 
stages there is a dry friction rub which can be heard by ausculta- 
tion and is often perceptible by palpation. Later as ejffusion oc- 
curs and percussion outlines the pericardial sac with the base 
below and near the sixth or seventh rib and the apex above at 
the second rib. As resolution takes place, absorption of the fluid 
occurs and the dullness in the pericardial region gradually be- 
comes normal in shape, the friction sound returns and in time 
disappears. 

DIFFERENTIAL DIAGNOSIS: Acute Endocarditis may 
be mistaken for this affection, but in this form of inflammation 
there are endocardial murmurs associated with the sounds of the 
heart and best heard over the location of the valves. The fric- 
tion sound which occurs in pericarditis and is loudest at the base 
of the heart, is not heard in cases of endocarditis. Effusion does 
not occur in this disease and is almost invariably present in peri- 
carditis. The outhne of the heart dullness is not altered in en- . 
docarditis, while in pericarditis it takes the shape of a triangle, I 
with the base below and apex above. 

Hypertrophy of the Heart is generally seen in athletes and 
those whose work requires extreme exertion. In this condition, 
the position of the apex beat is displaced downward and it is 
forcible, while the heart sounds are strong and unimpaired and 
the area of dullness is unaltered in shape, although slightly in- 
creased in size. 

Dilitation of the Heart is seen in individuals who have suffered 
from over-exertion or from some disease which has caused pro- 
longed disability. In this condition the pulse is weak, the apex 
beat is displaced downward and outward and is diffuse and not 
well marked. The area of dullness is unchanged, except that it 
is enlarged, while in pericarditis, dullness is due to the fluid sur- 
rounding the heart and is pryamidale in shape. 

HOUSE CONFINEMENT: As pericarditis usually follows 
or complicates a preceding disease, the duration of the illness 
causing disability is increased from i to 3 weeks and sometimes 
longer; this time depending on the physical condition of the pa- 
tient at the onset of this inflammation and the severity of it. 
When this disease follows as a complication and is severe, death 
may occur within 3 to 7 or 10 days after the beginning of the 
complication. 



PHLEBITIS 383 

TOTAL DISABILITY of the original disease is usually 
prolonged by this complication from 2 to 4 weeks. When the in- 
dividual has become greatly debilitated by the preceding illness, 
total disability may be increased from 4 to 6 or even 8 weeks. 
Cases which terminate fatally usually do so within a short time 
after the pericarditis supervenes and disability is thereby short- 
ened. Total disability from primary attacks of acute pericarditis 
lasts from 2 to 3 or 4 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
after house confinement has ended is allowable if provided by 
the policy and is usually short, from i to 2 or 3 weeks being sufiti- 
cient in the majority of cases. 

EFFECTS : Individuals having suffered with an attack of 
pericarditis are seldom insurable until at least six to twelve 
months have elapsed after complete recovery has ensued, when 
all forms of insurance could be granted after a medical examina- 
tion has been made and the report found satisfactory. 

PHLEBITIS 

SYNONYM : Inflammation of a vein. 

INFORMATION: Phlebitis is an inflammation of a vein 
or collection of veins and may be due to rheumatism, gout or 
tuberculosis, or follow typhoid fever or other infectious diseases. 
It is occasionally the result of an injury to the vein itself or from 
extension of inflammation which has been primarily caused by 
a wound. This inflammation more often involves the veins of 
the lower extremity. Varicose veins are prone to suffer from an 
inflammation due to injury or one of the above causes. 

SIGNS AND SYMPTOMS: Phlebitis in a superficial vein 
results in a cord-like swelling, with pain and tenderness over the 
part of the vein inflamed and a dusky red discoloration of the 
vSkin. When the inflammation involves the deeper veins there is 
no change in the color of the skin, but pain is present and be- 
comes severe on pressure, nodular, deep seated induration is pal- 
pable and swelling of the extremity is present below the point of 
inflammation. If the phlebitis is accidental in origin, evidence 
of an abrasion, laceration or contusion is apparent. 

DIFFERENTIAL DIAGNOSIS between phlebitis follow- 
ing an accidental injury and that due to some internal condition 
is important. If the individual carries an accident policy and this 
inflammation ensues, it must be caused bv an accident for dis- 



384 



DISEASES OF THE CIRCULATORY SYSTEM 



ability to be payable by the policy and unless external evidence 
of an injury is present or has existed, the inflammation is not 
likely to be accidental in origin. If a disability or general health 
policy is carried, indemnity is payable whether disability is due 
to an accident or the result of disease commencing within the cir- 
culatory system. 

HOUSE CONFINEMENT depends on the cause and loca- 




Fig. ICO. — Varicose veins. (In- 
ternational Text-Book of Surgery). 

tion of the inflammation. If phlebitis involves the upper extremi- 
ties or the head, from 5 to lo days are usually suflicient. Should 
the inflammation be situated in the veins of the lower Hmbs, from 
I to 3 or 4 weeks of house confinement may be necessary before 
the individual has sufiicientlv recovered to resume part of the oc- 




/ /\ 



PLATE IV 

FIO. 1 







/ 



Mf 



Mitral Regurgitation. 

FIG. 2 




WpMi^ 



t/ir/// 



M^ 



Mitral Stenosis. 

(M\isser) 



VALVULAR DISEASES OF THE HEART 385 

cupation. When an operation is necessary for phlebitis involv- 
ing the extremities, house confniement is increased from 2 to 
3 weeks from the date of operation. Should the phlebitis involve 
some of the veins of the skull, an operation is usually imperative; 
in which case house confinement lasts from 3 to 6 or 8 weeks 
after the date of operation. 

TOTAL DISABILITY depends on the location of the in- 
flammation and lasts from i to 2 or 3 weeks longer than house 
confinement; this time depending on whether an operation has 
been performed; if not, total disability practically ends at the ter- 
mination of house confinement, but if an operation has been 
necessary the above time may be required after house confine- 
ment has ended. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is short, seldom lasting more than from i to 2 or 3 weeks, 
according to the conditions described under total disability. 

EFFECTS: Individuals having suffered from an attack of 
phlebitis which was not suppurative, whether due to an accident 
or disease, are insurable for all kinds of insurance from three to 
six months after complete recovery. Should suppurative phle- 
bitis be suffered, such a condition is Hable to recur, when a health 
policy would not be issued without a waiver eliminating indem- 
nity for disability from this disease. In such cases, life insurance 
would not be considered until at least one year after the date of 
recovery and it would be necessary that the medical examination 
show an average risk. 

VALVULAR DISEASES OF THE HEART 

SYNONYMS: Chronic valvular disease; chronic endocar- 
ditis; sclerotic endocarditis; interstitial endocarditis. 

INFORMATION: Chronic endocarditis follows acute dis- 
ease of the endocardium and results in an impairment of the 
valves of the heart causing an improper closure of the orifices 
through which the blood passes. This produces murmurs whose 
point of greatest intensity marks the situation of the valve af- 
fected. This impairment of the valves of the heart follows acute 
diseases and is most common after attacks of acute articular 
rheumatism which occur in childhood or early adult life. The 
acute infectious diseases, such as scarlet fever, diphtheria, la 
grippe, etc., and chronic diseases, as syphilis, gout and Bright's 



386 DISEASES OF THE CIRCULATORY SYSTEM 

disease are also exciting causes. Excessive overwork in early 
life or a sudden strain put upon the heart by Hfting or attempting 
to perform a feat of strength are also said to result in valvular 
diseases. When disability is caused by valvular disease of the 
heart, it is almost invariably true that the impairment has been 
existing for months or years before the disability exists, unless 
there is a clear history of an act of over-exertion which might 
cause such a strain that would result in a heart murmur The 
usual history, however, of these cases is that the valvular disease 
has been existing for a long time and disability results as a 
gradual weakening of the heart occurs, either from excessive 
every day work or some acute disease 

SIGNS AND SYMPTOMS depend on the location of the 
diseased valve. The most common form of chronic endocarditis 
is mitral regurgitation which is characterized by a systolic mur- 
mur at the apex of the heart and this murmur is generally trans- 
mitted to the axilla. Next in frequency is aortic regurgitation 
resulting in a greatly enlarged heart and a diastolic murmur 
which is best heard over the second right intercostal space and 
transmitted down the side of the sternum towards the apex. This 
is the one form of chronic valvular disease that most commonly 
results in sudden death. Aortic obstruction is characterized by 
a systolic murmur which is best heard at the second right inter- 
costal space and is transmitted into the great vessels of the neck. 
Mitral stenosis is frequently associated with mitral regurgitation 
and results from an obstruction to the blood current as it passes 
through the mitral orifice. This form of valvular disease presents 
a pre-systolic murmur with its point of greatest intensity in the 
mitral area. Other murmurs are also heard in connection with 
the valves of the heart, but the above are the most frequent ones. 
In all cases of valvular disease, shortness of breath on exertion, 
pain over the region of the heart, dry cough and a characteristic 
pulse are present. 

DIFFERENTIAL DIAGNOSIS is unimportant as regards 
the issuance of an insurance policy, for the reason that no com- 
pany would insure an individual under an accident or health pol- 
icy, if it was known that any form of valvular heart disease was 
existing. Life insurance can be secured for those with impaired 
hearts only under the substandard form. When disability results 
under a health or general disability policy, individuals who suffer 
from aortic regurgitation are usually longer disabled than those 
suffering from the other forms. 



PLATE V 



FJG. 1 




Aortic Regurgitation. 

FIG. 2 




X 



Aortic Obstruction. 

(Musser) 



VALVULAR DISEASES OF THE HEART 387 

HOUSE CONFINEMENT when due to vahailar disease 
of the heart alone, does not ensue until that organ becomes so 
weak from the daily labor or an act of over-exertion, that the in- 
indivual is required to rest, when from i to 2 or 3 weeks in bed 
are usually sufficient for the heart to regain some of its strength 
and permit the occupation to be resumed. When the above time 
is lengthened, the physical condition of the individual is so poor 
that rest in bed of from 2 to 4 or 6 weeks is sometimes necessary 
before the heart regains some of its former tone. 

TOTAL DISABILITY depends on the age of the indi- 
vidual, the exact duties of the occupation and the form of valvular 
disease present. Preferred risks of middle age are usually not 
totally disabled longer than house confinement — from i to 2 or 
3 weeks. When the age is past fifty years and a sudden strain 
has taken place, death -may ensue or total disability last from 

2 to 4 weeks or more. Ordinary risks are totally disabled from 

3 to 6 or 8 weeks, when disability results from chronic valvular 
disease of the heart which has been brought on by excessive daily 
work or an act of over-exertion. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
when the policy requires house confinement and this form of in- 
demnity is payable, is usually short in preferred risks, not more 
than I to 2 weeks. Ordinary risks generally require from 2 to 4 
weeks of this form of disability after the termination of house 
confinement. 

EFFECTS : Individuals suffering from any form of valvular 
disease of the heart are not insurable for accident or health in- 
surance and when an insurance company learns that a policy- 
holder is suffering with such a disease or condition, the policy 
is cancelled at once. Life insurance can generally be secured by 
such persons under a substandard policy. 



PLATE VI 

FIG. 1. — Anterior Aspect. 




FIG. 2. — Posterior Aspect. 




\ 



Situation of the Viscera. 

Outlines of heart and vessels— broad, red lines. Margins of lungs and i ndi vid ual 

lobes— dotted green lines. Limits of pleural sacs— solid green lines. 

Liver— red shading. Stomach— green shading. 

(In part after H is-Spalteholz and Luschka.) fMusser.) 



CHAPTER XV 

DISEASES OF THE LUNGS AND RESPIRATORY SYSTEM 

ABSCESS OF THE LUNG 

SYNONYM: Circumscribed suppuration of the lung. 

INFORMATION: The most common form of abscess of 
the lung is that due to the bacillus of tuberculosis, but as such 
abscesses are usually multiple, they are not considered in this 
article. A circumscribed abscess of the lung is generally caused 
by streptococci or staphylococci and results from the extension 
of a suppurative inflammation in a neighboring part, such as the 
pleura or liver, from foreign bodies drawn into the lung or when 
these germs are transferred to an impaired part of the lung by the 
blood current. Wounds of the lung resulting from puncture by 
a foreign body or a puncture due to the fractured end of a rib, 
sometimes produce an abscess and in rare instances croupous 
pneumonia ends in this manner. 

SIGNS AND SYMPTOMS: Chills, high and irregular fever 
followed by profuse sweating indicates the formation of an ab- 
scess in this part of the body. There is dyspnea, cough with in- 
frequent, but profuse expectoration of offensive pus and shreds 
of lung tissue. On percussion, over the location of an abscess 
cavity and before it is emptied by a fit of coughing, dullness is 
elicited but after a coughing spell and expectoration, the cavity 
becomes filled with air when hyper-resonance exists. Large ab- 
scesses of the lungs can often be diagnosed by the x-rays and by 
a count of the leukocytes which are greatly increased in number 
under these circumstances. 

COMPLICATIONS: Gangrene of tJie Lung sometimes com- 
plicates or results from an abscess, when the signs and symptoms 
are practically the same with the exception that the breath is very 
foul and the odor of the expectorated matter is extremely of- 
fensive. Cases of gangrene are generally accompanied by an un- 
controllable diarrhea which produces, together with the lung con- 
dition, much exhaustion. Pulmonary hemorrhages sometimes 
occur in this condition. 

389 



390 DISEASES OP LUNGS AND RESPIRATORY SYSTEM 

HOUSE CONFINEMENT: When an abscess of the lung 
follows as a complication to some other disease, house confine- 
ment of the primary illness is generally prolonged from 2 to 3 
weeks when no operation is performed; if this is done, house con- 
finement is increased from 4 to 6 or 8 weeks. An abscess of the 
lung resulting from an external injury does not show marked 
signs or symptoms until from one to two weeks after the accident 
occurred, when house confinement may or may not be required; 
if so, from i to 3 weeks are generally sufficient. House confine- 
ment is usually prolonged from 4 to 6 weeks from the date of 
operation when this procedure becomes necessary. Some cases 
of abscess of the lung produce death within a short time and if 
this occurs, house confinement does not often last longer than 
I to 2 weeks. 

TOTAL DISABILITY is most uncertain in individuals suf- 
fering from an abscess in this location. When suppuration fol- 
lows an acute disease, the physical condition is already below par 
and total disabihty is greatly prolonged if death does not ensue. 
In such cases from 2 to 3 or 4 months of disability are not un- 
usual and sometimes these cases run longer than the limit of the 
policy. Total disability following an abscess of the lung resulting 
from an external injury or the drawing into the lungs of some 
foreign body, lasts from 4 to 6 or 10 weeks from the beginning 
of disability, this time including house confinement. An opera- 
tion always prolongs disability lasting from 4 to 6 or 8 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy is uncertain and depend-s on the location 
and size of the abscess, together with the physical condition and 
the method of treatment. 

EFFECTS: When an abscess of the lung results from an 
injury and recovery is complete, insurance of all kinds can be is- 
sued one year after the date of recovery. Individuals having 
suffered from an abscess due to some other cause in which dis- 
ability has been greatly prolonged are rarely insurable for any 
kind of a policy; certainly not until five to ten years have elapsed 
from the termination of the abscess and during which period no 
signs or symptoms occur which are referable to it. 

ASTHMA 

SYNONYMS: Bronchial asthma; essential asthma; spas^ 
modic asthma; nervous asthma. 



ASTHMA 



391 



INFORMATION : Asthma is described as a ''true neurosis 
of the respiratory apparatus" (Hughes) which results in a prob- 
able spasmodic contraction of the muscular layer surrounding 
the small bronchial tubes. It is more common in men than in 
women, occurs at any age and is more frequent in winter than in 
summer. The attack may last several hours, days or weeks and is 
usually excited by atmospheric changes, the inhalation of dust 
or odors of different kinds or a reflex irritation from the nasal 
chambers. 

SIGNS AND SYMPTOMS: An attack of asthma usually 
appears suddenly, although sometimes prodromes, such as a feel- 




Fi| 



lOi; — Bilateral enlargement of emphysema. 



Inner line — emphysematous chest. 

Outer line — a circle drawn to show how nearly the em- 
physematous approaches the circular shape. 
Dotted line — normal adult chest. 

Actual measurement in centimetres. 
Circumference — natural, 89.0 emphysematous, 87.75 
Transverse — " 29.6 " 27.25 

Anteroposterior — " 22.25 " 25.4 (Gee). 



ing of constriction surrounding the chest, sneezing, flatulency, 
coryza or a discharge of pale urine precedes the seizure.- The 
paroxysms of this disease most frequently occur in the early 
morning hours when the individual is awakened on account of not 
being able to breathe. This condition produces a flushed face* 
profuse perspiration, protrusion of the eyeballs, loud wheezing 
and great muscular inspiratory and expirator}^ eft'orts. Dyspnea 
sometimes becomes so severe that respiration almost ceases, and 
as this disappears, cough With expectoration occurs. The ex- 
pectoration contains delicate spirals of mucus (Curschmann's 
spirals) and octahedral crystals (Charcot-Leyden crystals). The 



392 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

paroxysms of asthma may last from a few minutes to several 
hours and in some cases daily attacks are suffered; these persist- 
ing for several weeks or more. Asthmatics are unable to expel 
the air from the lungs on account of the absence or degeneration 
of the elastic fibers surrounding the bronchioles and this results 
in dilitation of the lungs. This condition is recognized by hyper- 
resonance on percussion, and on auscultation absence of the in- 
spiratory murmur with prolonged expiration and numerous moist 
rales heard over both lungs. 

DIFFERENTIAL DIAGNOSIS: Hay Asthma occurs in 
May or June as a rose cold or in the autumn as an autumnal ca- 
tarrh The time of the occurrence of this disease, together with 
the sneezing and watery discharge from the nose and eyes which 
persists for days and does not occur in spasmodic attacks, marks 
•the difference between an attack of this and true asthma. 

Cardiac or Renal Asthma is a name applied to forms of dysp- 
nea which are produced by diseases of the heart or kidneys, and 
in such cases there is evidence of organic disease of these organs. 

Dyspnea due to diseases of the larynx or obstruction from 
foreign bodies, must be differentiated from dyspnea caused by 
asthma. Difficulty in breathing when caused by some form of 
obstruction in the larynx or bronchial tubes is not due to the in- 
dividual being unable to expel the air which is in the lungs, but 
is caused by a condition which prevents ingress of the air and if 
death occurs, it results from suffocation 

SEQUELAE: Emphysema of the lungs invariably results 
from repeated attacks of asthma and this condition becomes so 
pronounced that the form of the chest is altered, but disability is 
not caused by this sequels. 

Dilitation of the Right Ventricle follows attacks of asthma and 
is due to this disease and also to the emphysema which results 
from frequent attacks. As with emphysema, disability is not 
caused by this condition, but it may be prolonged in attacks of 
asthma when this complication is present. 

HOUSE CONFINEMENT: Attacks of asthma do not 
often require more than i to 2 days of house confinement, un- 
less the paroxysms are repeated at short intervals or every day 
for several days or more, when house confinement of i to 2 
weeks is not unusual. When asthma occurs during cold weather, 
house confinement may last from 2 to 3 or 4 weeks. 

TOTAL DISABILITY is never longer than from i to 2 or 
3 days in individuals suffering from an attack of asthma for the 



HAY ASTHMA 393 

first time, but as the paroxysms become more frequent the length 
of total disability is increased, but even under these conditions it 
is seldom over i week. When the attacks occur daily or nearly 
every day and last from one to two weeks or more, total dis- 
ability of from I to 3 or 4 weeks is often necessary. This is es- 
pecially true when asthma occurs during the winter months and 
is due to exhaustion following repeated paroxysms. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the poHcy after the termination of house confine- 
ment, does not often require more than i to 2 weeks, as any one 
suffering from this disease is generally sufficiently recovered to 
resume the occupation a short time after the last attack. 

EFFECTS : An individual having suffered with one or more 
attacks of asthma is an impaired risk. Life insurance can some- 
times be secured under the substandard form; while accident 
insurance can be written if all the other conditions are favorable. 
Health or disabihty insurance would hardly be given such a per- 
son even though a waiver be placed on the policy eliminating in- 
demnity for disability resulting from any disease or affection of 
the lungs Individuals with a history of having suffered from 
asthma during childhood in which little impairment has occurred, 
are insurable for all kinds of insurance when adult life is reached 
— if no evidence of the disease is present and no attack has oc- 
curred for ten years or more. 

HAY ASTHMA 

SYNONYMS: Hay fever; autumnal catarrh; rose fever; 
rose cold. 

INFORMATION: Hay asthma is an acute catarrhal in- 
flammation of the air passages, extending from the nose to the 
bronchial tubes and is caused by an irritation of the nasal mucous 
membrane by various odors, dust or vapors. It is limited to cer- 
tain seasons in the year; rose fever beginning in May or June and 
ending in July; while autumnal catarrh begins in August and ends 
with the first frost. 

SIGNS AND SYMPTOMS: An attack begins with redness 
and swelling of the eyes followed by a watery discharge. There 
is sneezing, with an increased flow of mucus from the nose, cough 
and difficulty in breathing. 

COMPLICATIONS: Pncimwnia sometimes follows or com- 
plicates a severe attack of hay asthma, and in such cases disability 



394 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

persists during the time required by the comphcation for recov- 
ery. ] 

Capillary Bronchitis may follow an attack of hay asthma and 
result in disability. For other information concerning this com- 
phcation, see article on Acute Bronchitis. 

Edema of the Lungs may ensue as a complication in cases of 
this disease in individuals greatly debilitated and also when the 
inflammation extends into the lungs. In such cases, disability 
results and death usually terminates the case within a short time 
after the onset of the complication. 

HOUSE CONFINEMENT: None for hay asthma, but 
complications almost invariably cause house confinement and this 
time is described under the comphcation. 

TOTAL DISABILITY seldom occurs in attacks of this ill- 
ness at the present day, for the reason that medical treatment 
can control the signs and symptoms sufficiently to permit the in- 
dividual to practically attend to all the duties of the occupation. 
This disease produces inconvenience, but seldom disability of 
more than from i to 2 or 3 days and this length of time is not 
covered by the majority of health or general disability policies, 
although some companies pay total disability of one or more days i 
when caused by illness. Sometimes a change of climate is 
thought necessary, but in such cases an insurance company would 
hesitate to pay total disability while an individual was away from 
his business for this reason. Hay asthma almost invariably has 
a history of previous attacks, therefore, unless the application for 
insurance stated this history, the company would not be liable for 
disability resulting from it, as no company would accept such a 
risk if a history of this disease was known — without a waiver 
eliminating indemnity for 'disability resulting from it. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY: 
This form of indemnity is not payable to any class of risks after 
an attack of hay asthma. 

EFFECTS : This disease does not affect the insurability of i 
an individual for accident insurance, but a health policy should • 
contain a waiver eliminating indemnity for disability resulting 
from it. If the attacks occur regularly every year, are very se- 
vere and prolonged, the issuance of life insurance would be ques- 
tionable. 



PLATE VII 



FIG. 1.— Right Lateral Aspect. 



FIG. 2.— Left Lateral Aspect 





i ^ 



Situation of the Viscera. 



Margins of lungs and of individual lobes— dotted green lines. Limits of pi 
saes— solid green lines. Liver and spleen— solid red lines. Diaphragm- 
dotted red lines. Stomach (portion not covered by 
lung)— green shading. 

I In part after Luschka.) iMusser.) 



eural 



ACUTE BRONCHITIS 395 

ACUTE BRONCHITIS 

SYNONYMS: Bronchitis; acute catarrhal bronchitis; bron- 
chial catarrh; acute bronchial catarrh; cold on the chest. 

INFORMATION: Acute bronchitis is a catarrhal inflam- 
mation of the bronchial tubes of the lungs and invariably is bi- 
lateral. It is more common in a cold damp climate with change- 
able weather and in occupations in which there is confinement or 
much dust or irritating vapor constantly in the air. An attack 
results from exposure when the body is overheated and some- 
times it follows some of the infectious diseases. The old form of 
limited health policies included bronchitis as one of the diseases 
for wdiich indemnity was payable, but on account of this disease 
complicating so many other diseases which were not enumerated 
in the policy and for which indemnity was not payable, it was 
necessary to eliminate it, as attending physicians invariably gave 
bronchitis as the cause of disabiHty — if it was present — whether 
as a complication or the primary disease. 

SIGNS AND SYMPTOMS: Acute bronchitis generally 
begins by a nasal cold which is accompanied by chilliness, vague 
pains throughout the body and lack of energy. This persists for 
one to two days when the cold seems to center in the chest pro- 
ducing a cough with little expectoration, fever from ioo° to 102° 
F, with a sense of constriction over the chest and pain behind the 
sternum which is increased by deep breathing, sneezing or cough- 
ing. As the inflammation progresses, expectoration increases 
and finally a greenish-yellow, profuse, mucous discharge results. 
On auscultation in the earlier stages, there is harsh breathing 
over both lungs and later on this persists, but is accompanied by 
moist, mucous rales. 

DIFFERENTIAL DIAGNOSIS: Croupous Pneuiuonia is 
diagnosed from acute bronchitis by the more sudden onset, in- 
creased severity of the symptoms, dullness on percussion, this 
usually being unilateral and the progress of the disease. 

Catarrhal Pneumonia is sometimes mistaken for acute bron- 
chitis, but in this disease there is a gradual elevation of tempera- 
ture until 102° and 103° F are reached and this is accompanied 
with cyanosis, rapid, shallow and laborious breathing, frequent 
pulse, dry, hacking cough, prostration and physical signs indi- 
cating consolidation of certain sections of the lungs. 

Acute Miliary Tuberculosis sometimes closely resembles acute 
bronchitis, but in the former there are more marked svstemic 



396 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

symptoms with a high temperature persisting for weeks, in- 
creased number of respirations and tubercule bacilli in the 
sputum. 

Influenza is almost invariably accompanied by more or less 
inflammation of the bronchial tubes. In this disease there is 
marked prostration with severe pains in the head, back and limbs, 
high fever and rapid pulse. Insurance companies pay more 
fraudulent claims under limited health policies which pay indem- 
nity for bronchitis, when the disabiUty is due to influenza, than all 
other fraudulent claims combined. It is a regrettable fact, but 
nevertheless true, that physicians will certify that bronchitis is 
the cause of disability in the majority of cases when this inflam- 
mation is present as a complication of la grippe and is not the 
primary illness. 

COMPLICATIONS: Pneumonia may follow an attack of 
bronchitis when the usual signs and symptorns characteristic of 
this disease become apparent. If this compHcation arises, dis- 
ability is prolonged according to the time described under Croup- 
ous Pneumonia. 

Pleurisy sometimes supervenes during an attack of bronchitis 
when unnecessary exposure has been suffered. In these cases, 
the compHcation is easily diagnosed by the sharp, lancinating 
pain in the side which is increased by deep breathing or cough- 
ing and the physical signs of a friction sound over the spot of in- 
flammation. Disability is prolonged when this complication 
arises according to the time required for this localized inflamma- 
tion to disappear. 

Acute Tuberculosis of the Liings may develop after an attack 
of acute bronchitis which apparently does not result in recovery. 
It is most likely, however, that the tuberculosis has already been 
exisiting and when the attack of acute bronchitis occurs, the tuber- 
culous infection is aggravated and the signs and symptoms be- 
come sufficiently marked to be noticed after an attack of bron- 
chitis. 

HOUSE CONFINEMENT lasts from 7 to 10 days in the 
average case in all classes of risks. When the disease occurs in 
the winter months and the termination is during cold, damp and 
wet weather, house confinement is increased from i to 3 or 5 days 
on account of this outside condition. Severe cases of acute bron- 
chitis require from 2 to 3 or 4 weeks of house confinement and 
those in which the disease becomes subacute, from 4 to 6 weeks 
in the house are necessarv. 



ACUTE NASAL CATARRH 397 

TOTAL DISABILITY in the majority of cases lasts from 
10 to 20 da3^s, the average time, however, being 2 weeks. This 
may be increased or diminished according to the season of the 
year and the weather condition. If in winter and during incle- 
ment weather, it is generally increased i to 2 weeks; while if the 
disease occurs during the summer months, total disability is short, 
not often over 7 to 10 days. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, should not require more than from 3 to 7 days. Indi- 
viduals who have suffered an attack of bronchitis are seldom to- 
tally disabled but a few days after house confinement has ended; 
consequently, this form of disability is not often considered in a 
settlement. 

EFFECTS : An ordinary attack of acute bronchitis that is 
terminated by a good recovery has no bearing on the insurabil- 
ity of an individual for insurance of any kind. Life insurance, 
however, would not be written on such a risk when there has 
been a history of repeated attacks, until at least two to three 
years have passed without any symptoms referable to this dis- 
ease, when if a medical examination shows the lungs normal, this 
form of insurance could be safely granted. Individuals suffering 
an attack of bronchitis in the fall are not insurable for a health 
policy until after the following spring, unless a waiver is placed 
on the policy eliminating indemnity for diseases of the lungs. Ac- 
cident insurance can be written on such a person as soon as com- 
plete recovery ensues. 

ACUTE NASAL CATARRH 

SYNONYMS: Acute coryza; acute rhinitis; cold in the 
head. 

INFORMATION : Rhinitis is an acute catarrhal inflamma- 
tion of the mucous membrane lining the nasal cavities and is 
most frequently caused by exposure, but sometimes results from 
the inhalation of irritating vapors, gases and dust. It also occurs 
in conjunction with certain epidemic diseases, such as measles 
and influenza. 

SIGNS AND SYMPTOMS: A cold begins with chilliness, 
sneezing, running of the nose, headache and a general feeling of 
malaise. This is soon followed by slight fever, increased dis- 
charge from the nose which in time becomes muco-purulent, loss 



-«*^ww^ 



398 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

of appetite and constipation. The mucous membrane lining the 
nares becomes inflamed and swollen, preventing a free movement 
of the air through the nose and causing much inconvenience in 
breathing. In some individuals, a cold extends down and involves ^ 
the bronchial tubes, when the signs and symptoms of bronchitis 
which are more or less marked are evident. 

DIFFERENTIAL DIAGNOSIS: Measles begin -with a 
catarrhal condition of the nose and throat and may be thought in 
the beginning to be only an ordinary cold, but in this disease the 
temperature rises rapidly to 103° or 104° F. The second day the 
temperature declines some and does not rise again until the third 
or fourth day, when the characteristic eruption appears and marks 
the disease as something more than an acute coryza. 

COMPLICATIONS: A Mild Conjiinctwitis sometimes ac- 
companies and complicates a severe cold of the head, when total 
disability if not present on account of the cold, results from the 
eye conditions and lasts according to the time described under 
this subject. 

Pharyngitis and Laryngitis result from an extension down- 
ward of the inflammation which involves the posterior nares, 
causing pain and difliculty in swallowing and more or less loss 
of the voice. Inflammation involving the larynx and pharynx are 
common complications of colds but usually they do not produce 
or prolong disability, unless the individual is one whose occupa- 
tion requires constant use of the voice, such as ministers, actors 
and public lecturers, when total disability is increased by the 
complication and the length of time is described under Acute 
Laryngitis. 

Acute Abscess of the Middle Ear may result from an inflam- 
mation of the Eustachian tube which follows a severe cold of the 
head. When this complication arises, disability is prolonged and 
is described under Abscess of the Middle Ear. 

HOUSE CONFINEMENT: Acute colds in individuals who 
are in good health, seldom produce any house confinement. 
When the cold is exceedingly severe, house confinement of 3 to 
7 days may be necessary, and this is sometimes prolonged from 1 
I to 2 or 3 days when a cold ends during damp, wet weather. If 1 
any of the complications arise, house confinement is prolonged 
according to the time required for recovery of the complication. 

TOTAL DISABILITY is not allowable for this condition 
unless house confinement has ensued, when the length of time for 
which indemnity is payable is the time covered by house confine- 



3 



DIPHTHERIA 399 

ment and that time is rarely over i week. The majority of heahh 
pohcies do not pay for disabiHty resulting from a cold, on account 
of requiring at least one week of total disability before any in- 
demnity is payable. Some companies, however, will pay indem- 
nity for total disability when the time is less than seven days, and 
in such cases the individual is entitled to total disability for the 
time that house confinement lasted. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, should not be allowed in attacks of acute coryza. 

EFFECTS : When a history of repeated colds exists and 
these last from one to two or three weeks and even though they 
do not cause total disabiHty, an insurance company would hardly 
issue a health policy without a medical examination. Accident 
insurance, however, could be granted at ajiy time, provided the 
other conditions were normal. The issuance of life insurance 
would depend on the result of the medical examination, whether 
it showed any involvement of the lungs or not; also the physical 
condition of the individual, family history, etc. If these were all 
favorable, it is probable that this form of insurance would be is- 
sued by all companies. 

DIPHTHERIA 

SYNONYMS: Membranous croup; membranous angina; 
putrid sore-throat; mahgnant ulcerous sore-throat. 

INFORMATION: Diphtheria is an acute, contagious con- 
stitutional disease and is caused by a specific germ — the Klebs- 
Loeffler bacillus — which produces the disease two to seven days 
after infection occurs. It is more or less prevalent during all 
seasons of the year, but is more common during cold, damp 
weather and is more frequent in early childhood, although it is 
often seen in adult life. Any condition of weather or living which 
results in a deteriorated physical condition may be followed by 
an attack of this disease. The local symptoms involve the throat 
and are due to the growth of the germs and the swelling pro- 
duced thereby; while the constitutional symptoms are the result 
of toxins produced by the bacillus and absorbed into the circula- 
tion. 

SIGNS AND SYMPTOMS: The onset of this disease may 
be gradual, when there occurs a mild chill accompanied by a sore- 
throat, headache, loss of appetite, tenderness around the angle 



wp 



400 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

of the jaws, stiffness of the neck and moderate fever running from || 
102° to 104° F. When the attack begins suddenly, there is a 
severe chill or prolonged chilliness, followed by increased tem- 
perature which reaches 103° to 105° F, difftcult and painful deglu- m 
tition, loss of strength and prostration. The pulse is rapid and 
feeble, the urine is scanty and often contains albumin and the 
bowels in the majority of cases are constipated; swelling and ten- 
derness of the lymphatic glands of the neck always accompany 
this disease. Cough with expectoration of mucus is an annoying 
condition and in violent fits of coughing, shreds of membrane are 
torn off and ejected. On examination, the throat is found to be 
red, swollen and inflamed and covered with the diphtheritic mem- 
brane which is of a gray or grayish-yellow tinge and is found on 
the tonsils, the pillars of the fauces and the pharynx. Sometimes 
this membrane extends into the nose, mouth and larynx, produc- 
ing nasal or laryngeal diphtheria. In cases with a nasal involve- 
ment there is a discharge from the nose and epistaxis; when the 
larynx is affected, hoarseness or loss of voice follows. These 
forms of diphtheria are usually secondary and when present de- 
note a severe infection. The false membrane which results from 
the action of the bacillus on the mucous membrane, has an offen- 
sive odor and when dislodged leaves a raw, bleeding surface. 

DIFFERENTIAL DIAGNOSIS: Diphtheria is positively 
diagnosed by securing a culture of the germ and growing it, when 
the specific Klebs-Loefffer bacillus is found and the existence of 
this germ is pathognomonic of diphtheria. 

Pharyngitis resembles diphtheria when this disease is in its 
earlier stages before the false membrane forms, but as soon as 
this becomes well marked, the diagnosis is easily made and this 
is especially true if a culture has been obtained. 

Follicular Tonsilitis is characterized by swelling that is limited 
to the tonsils which are red and swollen and which may be cov- 
ered with a false membrane resembling that found in diphtheria. 
Absence of the continuation of severe constitutional symptoms 
and the specific bacillus of diphtheria marks the difference be- 
tween this disease and true diphtheria. 

Scarlet Fever in the earlier stages shows the mouth and 
pharnyx highly inflamed, but in this disease there is the charac- 
teristic strawberry tongue and rapid pulse which is out of all pro- 
portion to the temperature. The second day of the disease a 
diffuse red rash appears and covers the whole body and this is not 



PLATE VI II 




Beginning or early stage of Diphtheria. 




Second day of disease, showing development of Menibran< 

(H. K. Mill ford Co.1 



EMPHYSEMA 401 

present in diphtheria and neither is the bacillus of diphtheria 
found. 

COMPLICATIONS involving the nose, middle ear, bron- 
chial tubes and lungs often follow diphtheria and when present 
disabilit}^ is prolonged according to the time required for the 
recovery of the complication. 

SEQUELAE: Post-Diphtheritic Paralysis is the most im- 
portant sequelae to this disease and is said to occur in about fif- 
teen per cent, of all cases. Paralysis of the pharynx is most fre- 
quent, followed in turn by involvement of the eyes, heart and 
extremities. Paralysis involving the heart is the most serious 
sequelae and often produces an unexpected fatal termination when 
the disease is thought to have subsided. 

HOUSE CONFINEMENT lasts from i to 2 weeks in ordi- 
nary attacks of this disease when occurring in adults. Severe at- 
tacks of diphtheria require from 2 to 3 weeks of house confine- 
ment with an additional 5 to 10 days when a relapse occurs or 
when the weather conditions are unfavorable for the individual to 
leave the house. 

TOTAL DISABILITY in the average case affecting an in- 
dividual, lasts from 10 to 20 days; severe attacks require from 3 
to 4 weeks. If a complication occurs, total disability is prolonged 
according to the complication; while if a sequelae follows, such as 
paralysis of the throat or heart ensues, total disability may be in- 
creased I to 2 weeks and sometimes longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment usually does not require more than i to 2 weeks in all 
classes of risks. 

EFFECTS: Individuals having suffered from a mild or se- 
vere attack of diphtheria, are insurable for all forms of insurance 
from three to six months after the date of complete recovery, — 
provided paralysis has not followed the attack. If this has oc- 
curred or complications ensued, life or health insurance would not 
be issued until after a medical examination, but accident insur- 
ance could be safely written at this time if no permanent paralysis 
of the heart or extremities was present. 

EMPHYSEMA 

SYNONYMS: Pulmonary emphysema; vesicular emphy- 
sema. 
26 



402 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 



INFORMATION: Emphysema of the lung is an over dis 
tention of the air vesicles as the result of too forcible inspiration 
or excessive distention by forced expiration. The upper portion' 
of the lungs and especially the left side is the site most often 
affected. It is more common in middle life and with certain occu- 
pations which require excessive expiratory efforts, such as musi- 
cians using wind instruments, glass blowers, etc. 

SIGNS AND SYMPTOMS : The most pronounced symp- 
tom of this disease is dyspnea which is more marked after exer- 
tion. When a slight bronchitis occurs in conjunction with this 
dilitation, some cough exists with more or less expectoration. 
Old cases are usually complicated with dilitation of the heart, 
when the signs and sym.ptoms referable to this condition are pres- 
ent. Inspection generally shows a rounded chest with the antero- 
posterior diameter increased, causing it to be known as the ''bar- 
rel-shaped" chest. On auscultation the respiratory murmur is 
greatly weakened and often inaudible. Rales which are due to 
the accompanying bronchitis are also heard. 

DIFFERENTIAL DIAGNOSIS : Chronic Bronchitis might 
be mistaken for a case of emphysema in the earlier stages, but 
when this condition is present no change is noticed in the for- 
mation of the chest and marked dyspnea is absent The percus- 
sion note is unchanged and not high pitched as in emphysema^ 
while the A'esicular murmur is harsh and roughened in bronchitis 
and in emphysema it is absent or scarcely perceptible. 

Pneumothorax is usually sudden in onset and almost invari- 
ably is unilateral. The vesicular murmur is absent over the air 
cavity and diminished over the part of the lung that is com- 
pressed. 

Spasmodic Asthma occurs in paroxysms and during the in- 
terval there is absence of symptoms indicating dilitation of the 
lungs; while in emphysema these signs and symptoms are con- 
stantly present. 

COMPLICATIONS : Diseases of the Lnngs including asthma 
and bronchitis together with dilitation of the heart, frequently 
complicate this disease. When pneumonia supervenes in lungs 
already impaired by em.physema, a fatal termination usually takes 
place. 

HOUSE CONFINEMENT seldom occurs in cases of em- 
physema that are not complicated with somie acute disease of the 
lungs or with pronounced and chronic dilitation of the heart. If 
any lung complication ensues the length of house confinement is 



1 



HEMOPTYSIS 403 

governed by the complication. When dihtation of the heart fol- 
lows or accompanies emphysema,- house confinement is uncer- 
tain; depending on the age and occupation of the individual, to- 
gether with the length of time emphysema has been present and 
also the degree of dilitation which has- taken place. 

TOTAL DISABILITY is not often present until emphysema 
becomes compHcated with some acute disease, when the length 
of time is governed by the complication. If dilitation of the heart 
is present and is pronounced and the individual is passed middle 
life, total disability may occur and last an indefinite time. How- 
ever, 2 to 4 weeks are generally long enough for any one to suffi- 
ciently recover from such a condition as to enable some part of the 
occupation being resumed. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is determined by the complication which causes house con- 
finement or total disability. 

EFFECTS : AVhen emphysema of the lungs exists in an in- 
dividual, that person is not insurable for a life or health policy. 
Accident insurance, however, can usually be written if all other 
conditions are favorable; each case, however, should be consid- 
ered by itself. 

HEMOPTYSIS 

SYNONYMS: Hemorrhage; bronchial hemorrhage; bron- 
cho-pulmonary hemorrhage; bronchorrhagia. 

INFORMATION : Hemorrhage from the lungs may be due 
to a number of causes, the most frequent one probably being tu- 
berculosis. This condition also occurs on account of excessive 
cardiac action, rupture of an aortic aneurysm, certain blood dis- 
eases as leukemia, purpura, etc., ulcers or injuries to the larynx 
or trachea, excessive over-exertion and traumatism involving the 
lungs. It is very important in an insurance examination that the 
exact cause and source of a hemorrhage from the mouth or nose 
be ascertained. If this is not done a rejection or cancellation of- 
a policy may be the result, and if the hemorrhage is only a trivial 
one and comes from the nose or gums and has absolutely no bear- 
ing on the longevity or impairment of the risk, an injustice is' 
done to the applicant, the agent and the company. Cases with a 
history of a hemorrhage from the lungs are looked upon with 
suspicion and unless it can be demonstrated that the heniorrhao-e 



404 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

is not caused by a tuberculous condition, the individual is not 
considered insurable until some years after it has occurred; while 
if the bleeding is due to a temporary condition which results in a 
hemorrhage from the respiratory tract or the stomach, ah forms 
of insurance may be issued a short time after the hemorrhage oc- 
curred. 

SIGNS AND SYMPTOMS : A hemorrhage from the lungs 
occurs suddenly and first shovvs itself by a sensation of warmth 
in the chest, followed by tickling in the throat and a salty fluid 
in the mouth which is expectorated with or without coughing. 
The blood is of a bright red color, freely mixed with air which 
gives it a frothy appearance and may amount from one or two to 
eight or twxlve ounces. Generally, however, the hemorrhage is 
small in quantity, unless it is the result of a ruptured aneurysm 
when it is excessive and continues until death results. When a 
hemorrhage from the lungs ceases, the mucus which is expec- 
torated is blood tinged for a number of days. On auscultation, 
bubbling rales are heard over certain portions of the chest that 
mark the location from which the hemorrhage occurred. 

DIFFERENTIAL DIAGNOSIS: Epitaxis or hemorrhage 
from the nose occurs through the nostrils, although some of the 
blood may be expectorated; cough is absent and the blood is un- 
mixed with air or mucus, and examination of the nostrils and pos- 
terior nasal cavities will show the point from which the bleeding 
occurred. 

Hemateinesis or hemorrhage from the stomach is diagnosed 
by the fact that in this condition the blood is vomited and is not 
expectorated b}^ coughing. It is dark in color, clotted, acid in 
reaction and mixed with the contents of the stomach. In such 
cases the blood may come from the lungs and be swallowed, when 
an examination of the chest will serve to distinguish any impair- 
ment. If the hemorrhage comes from the stomach alone, rales 
are absent in the lungs. 

COMPLICATIONS: Tuberculosis of the Lungs or other 
diseases involving these organs are usually present when hem- 
optysis occurs, and the length of disability is governed by the 
primary affection and not by the hemorrhage which is generally 
a symptom of the more serious disease. 

Ulcer of the Stomach may be the cause of hematemesis and un- 
less disability results from the hemorrhage being excessive or 
peritonitis ensues from a rupture of the ulcer into the peritoneal 
cavity, disability is not often caused by the bleeding. 



INFLUENZA 405 

HOUSE CONFINEMENT is often existing when a hemor- 
rhage occurs on account of some lung disease. If this is not the 
case, house confinement lasts from 2 or 3 days to 2 or 3 weeks; 
this time depending on the occupation of the individual, the phy- 
sical condition, the amount of blood lost and the extent of in- 
volvement of the lungs by the disease which causes the hemor- 
rhage. 

TOTAL DISABILITY in individuals suffering from a pul- 
monary hemorrhage for the first few times, seldom lasts more 
than from 2 to 7 days, unless the hemorrhage has been excessive 
when from 2 to 3 weeks may be necessary on account of the weak- 
ened condition from the loss of blood. Individuals suffering 
from pulmonary tuberculosis which has advanced beyond the 
earlier stages, are often totally disabled when the hemorrhage oc- 
curs and the bleeding does not alter the surrounding conditions, 
except to confine the person to bed. Hemorrhage from the lungs 
or stomach when due to an accident or from the stomach when a 
diseased condition exists, is only a sign of injury or disease and 
total disability is governed by the character and results of the 
accident or disease. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is indefinite and depends on a number of conditions. If a 
hemorrhage from the lungs due to tuberculosis, it may require 
the limit of the policy; while if due to an ulcer or other disease 
of the stomach it may only last from i to 2 or 3 weeks. 

EFFECTS : Cases with a history of a hemorrhage from the 
lungs that is not accidental in origin are uninsurable for a 'life 
policy until at least five years have elapsed without any evidence 
of a recurrence; a health policy can generally be issued from six 
to twelve months after the date of hemorrhage by eliminating 
indemnity for any disease of the respiratory organs; while an ac- 
cident policy could be issued at the same time if the individual 
was apparently in good health. When the hemorrhage has been 
due to an accidental injury, all forms of insurance can be safely 
written from six to twelve months after complete recovery has 
taken place and no signs or symptoms have occurred during that 
interval. 

INFLUENZA 

SYNONYMS: La grippe; epidemic fever; epidemic catarrh: 
contagious fever; catarrhal fever. 



406 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

INFORMATION : Influenza is an acute infectious disease 
that usually occurs in epidemics, although it is generally endemic. 
It is caused by an extreme^ small bacillus discovered in 1892 by 
Pfeiffer. One attack does not confer immunity and neither sex is 
more susceptible than the other. At the present day the word 
''la grippe" is applied by a great number of people to a severe 
cold which is complicated or accompanied by more or less bron- 
chitis. An individual carrying one of the old special health poli- 
cies that named bronchitis as one of the diseases for which in- 
demnity was payable, considered it perfectly right to make a 
claim when the cause of the disability was either la grippe or a 
severe cold and allege that the illness was due to bronchitis. On 
account of a number of claims having been paid under false rep- 
resentations by claimants and attending physicians, it was neces- 
sar}^ for insurance companies to eliminate bronchitis as one of the 
diseases for which indemnity was payable by this form of policy. 

SIGNS AND SYMPTOMS: The onset of influenza in the 
majority of cases is sudden, beginning with a chill or chilliness, 
lassitude, pain in the head and back which is followed by fever, 
the temperature running as high as 101° to 103° F. This is ac- 
companied b}^ a rapid pulse, sneezing, redness of the eyes, hoarse- 
ness, cough with little or no expectoration, coated tongue, nau- 
sea, sometimes vomiting, frequently diarrhea and great prostra- 
tion. This condition continues for three to seven days, when a 
slow convalescence begins or a relapse occurs and complications 
set in; the latter being especially true in the aged. The signs 
and symptoms of this disease are extremely variable, sometimes 
more markedly referring to the respiratory tract, other times the 
most important symptoms are gastro-intestinal, while again ner- 
vous symptoms are more prominent. 

COMPLICATIONS: Aaife Bronchitis may accompany or 
follow an attack of this disease, when the signs of involvement 
of the bronchial tubes are apparent on examination of the chest. 

Pneumonia frequently follows in the aged who have suffered 
an attack of influenza. This occurs most often when the indi- 
vidual is an alcoholic or has suffered from exposure at the time 
influenza is contracted. 

HOUSE CONFINEMENT lasts from i to 2 weeks in gen- 
uine cases of la grippe and this is sometimes increased from 7 to 
TO days, when the attack occurs in the aged or in those debili- 
tated from any cause and when severe relapses have been suf- 
fered. Complications which accompany this disease prolong 



I 



ACUTE CATARRHAL LARYNGITIS 407 

house confinement and are described under the name of the com- 
plication. 

TOTAL DISABILITY lasts from i to 3 weeks, the average 
case being from 10 to 14 days. Each relapse that takes place 
prolongs the period of disabihty from 3 to 7 days and if the ter- 
mination occurs during damp, wet weather, disability is increased 
from 2 to 4 days. Should complications arise, the length of total 
disability depends on the complication, the severity of it, and also 
the original disease, the age and physical condition of the indi- 
vidual. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, may require from i to ^ or 3 weeks in cases where the at- 
tack has been severe and the physical condition of the party is 
much weakened or the age is well advanced. 

EFFECTS : Persons under fifty years of age are insurable 
for any kind of a policy from two to three months after com- 
plete recovery from an attack of la grippe. When the age is be- 
yond this limit, it is advisable that a medical examination be made 
before life or health insurance is granted. Accident insurance 
may be issued from one to two months after an attack of la grippe, 
when recovery has been sufficiently complete to prevent any spe- 
cial liability to accidents. 

ACUTE CATARRHAL LARYNGITIS 



SYNONYMS: Laryngitis; catarrhal laryngitis; sore-throat. 

INFORMATION : Acute catarrhal laryngitis is an acute in- 
flammation of the mucous membrane of the larAmx and is caused 
by exposure and atmospheric changes, the inhalation of irritating 
dust or vapors, improper use of the voice and sometimes by the 
lodgment of a foreign body in the larynx. 

SIGNS AND SYMPTOMS : An attack of laryngitis is sud- 
den in onset and begins with a feeling of dryness and tickling in 
the back of the mouth; this is soon followed by hoarseness, dry 
cough and pain in the throat which is increased on talking, cough- 
ing or swallowing. The tongue is coated, appetite is poor and 
slight elevation of the temperature occurs. As the inflammation 
progresses, the hoarseness becomes more marked until it ter- 
minates in entire loss of the voice; the cough loses its harsh, drv 
character and is accompanied by expectoration which in some 



408 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

cases is blood streaked. Examination of the throat shows the 
mucous membrane of the larynx to be red, swollen and injected. 

DIFFERENTIAL DIAGNOSIS : Edematous Laryngitis or 
edema of the glottis may result from an acute attack of inflamma- 
tion in this situation or follow some of the infectious diseases. 
The signs and symptoms are about the same as those occurring in 
acute laryngitis, in addition to which there occurs difficulty in 
breathing and deglutition; as the edema gradually increases, the 
difficulty in respiration becomes more pronounced and unless sur- 
gery intervenes death finally terminates the case. This form of 
laryngitis often develops when a chronic inflammation is existing, 
especially if ulceration of the larynx is present. 

Spasmodic Laryngitis or false croup is most common in chil- 
dren and is diagnosed by the attacks occurring chiefly during the 
night and coming on in paroxysms with a dry cough and difficulty 
in respiration. 

Croupous Laryngitis is regarded by most authorities as diph- 
theritic in character and is caused by the Klebs-Loeffier bacillus. 
This disease is sudden in onset and usually occurs in children, be- 
ginning with hoarseness of the voice, cough which is croupy in 
character, difficulty in breathing and attacks of spasm of the 
glottis whcih causes momentary suffocation, during which the 
face is cyanosed and extreme inspiratory efforts are made. 

COMPLICATIONS : Ulcers of the Larynx result when acute 
laryngitis has been caused by the impaction of a foreign body. In 
such cases, disability is not prolonged except in individuals who 
require constant use of the voice which may not become normal 
for weeks or months. 

Diphtheritic Laryngitis often occurs during an attack of diph- 
theria from an extension of the original disease. In such cases, 
disability is greatly prolonged and the length of time is controlled 
by the more serious disease. 

HOUSE CONFINEMENT lasts from 7 to 10 days in the 
average case, due to the result of exposure or cold. When the 
inflammation is very severe from 2 to 3 weeks in the house may 
be necessary. If the termination of the disease occurs during 
cold and damp weather, the above time is increased from 2 to 3 
or 4 days. 

TOTAL DISABILITY is usually payable for the time that 
house confinement existed and in the ordinary case from i to 2 
weeks are generally sufficient. Severe cases may require from 
2 to 3 weeks of total disability and this time is almost always 



CONGESTION OF THE LUNGS 409 

necessary in individuals whose occupation requires constant use 
of the voice. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, may require from i to 2 weeks in cases where the occupa- 
tion requires singing, public speaking or much use of the voice. 

EFFECTS : Insurance of all kinds can be issued from two to 
four weeks after an attack of laryngitis, provided complete recov- 
ery takes place and the inflammation is not tuberculous in char- 
acter. If there is a history of repeated attacks, health insurance 
would not be issued without a waiver eliminating indemnity for 
this disease. 

CONGESTION OF THE LUNGS 

SYNONYMS: Hypostatic congestion; pulmonary engorge- 
ment. 

INFORMATION : Congestion of the lungs when given as 
the cause of disability by attending physicians, usually means 
that the individual suffered from the first stage of pneumonia. If 
the claimant carried a special health policy in which indemnity 
was payable for disability due to pneumonia and the first stage 
of this disease only was present, he would not be entitled to in- 
demnity under the contract. If a general disability policy is car- 
ried, it of course makes no difference whether the disease be- 
comes fully developed or not. Congestion of the lungs may be 
caused by the inhalation of hot air, steam and irritating vapors; 
it may be the beginning stage of pneumonia or associated with 
other diseases of the lungs or pleura. 

SIGNS AND SYMPTOMS: An attack of congestion of 
the lungs when it is the early stage of pneumonia, usually follows 
from exposure and is accompanied, by a general cold, cough and 
expectoration of blood-streaked mucus, with slight pain in the 
chest and great difficulty in breathing; the pulse is increased and 
the temperature slightly elevated. On examination of the chest, 
broncho-vesicular breathing and subcrepitant rales are present 
over the area involved. 

COMPLICATIONS: Bronchitis usually accompanies or 
complicates congestion of the lungs. When present, however, 
house confinement or disability is not often lengthened bv this 
involvement. 

Pneumonia most frequently follows acute congestion of the 



410 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

lungs which is simply the first stage of this disease. When pneu- 
monia becomes fully developed, total disabiHty is described under 
this disease. 

HOUSE CONFINEMENT lasts from 5 to 10 days in at- 
tacks of congestion of the lungs and this is sometimes increased 
from I to 3 or 4 days when the termination of the attack occurs 
in winter or, during inclement v/eather. 

TOTAL DISABILITY of i to 2 weeks is demanded by all 
classes of risks after an attack of acute congestion of the lungs. 
Very few uncomplicated cases require over 2 Aveeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy is almost never necessary in these cases. . 

EFFECTS : When acute congestion of the lungs occurs 
during the fall or winter, months, the individual is not insurable 
for a life or health policy until'the following summer. If it oc- 
curs in the spring or summer, all forms of insurance can be writ- 
ten from two to three months after complete recovery. Acci- 
dent insurance, however, can be issued from one to two months 
after complete recovery from an attack of this congestion, irre- 
spective of the weather conditions. 

PLEURITIS 

SYNONYMS: Pleurisy; inflammation of the pleura; stitch 
in the side. 

INFORMATION: Pleurisy is an acute inflammation of the 
pleura, usually unilateral and is caused by exposure, traumatism 
to the chest walls and in many cases is secondary to diseases of 
the lungs, diseases below^ the diaphragm, pericarditis, infectious 
fevers, rheumatism and Bright's disease. 

SIGNS AND SYMPTOMS: Acute pleurisy when not a 
complication, begins with a chill and sharp lancinating pain in the 
affected side and this is aggravated by coughing, breathing or 
sneezing. Respirations are increased in number and are shallow^ 
moderate fever develops, running from 101° to 103° F, and the 
pulse is increased to ninety or one hundred per minute. As the 
effusion collects, dyspnea becomes marked and is accompanied 
by cough and evidence of cardiac embarrassment exists. Inspec- 
tion shows deficient expansion on the affected side and bulging 
of the intercostal spaces with displacement of the apex beat; on 
percussion dullness over the fluid is elicited and above, over the 
lung, tympanitic resonance. Auscultation and sometimes palpa- 



PLATE IX 



FIG. l.-Ante 



nor Aspect 




/ 




M 



j. 



FIG. 2.— Posterior Aspeel 







/x 



f ' 



Pleurisy with EHusiou ,r.glu-sided). 
(Musser) 



PLEURITIS 411 

tion in the earlier stages reveal a friction sound and absence of the 
respiratory murmur. As the fluid collects, the friction sound dis- 
appears and reappears as it is absorbed. 

DIFFERENTIAL DIAGNOSIS: Pneumonia is diagnosed 
from pleurisy by the character of its beginning with a severe cold 
and high fever, rusty expectoration, crepitant rales and no dis- 
placement of the apex beat. 

Pericarditis zvifh Effusion is characterized by dullness which 
is pyramidal in shape with the base below and the apex pointing 
above, the heart sounds are distant and muffled and cardiac em- 
barrassment is present. 

Enlargement of the Liver is sometimes mistaken for pleurisy 
with effusion, but in this condition the upper line of dullness is 
depressed on deep inspiration and elevated on expiration. 

Pleurodynia is pain in the intercostal muscles and is dififeren- 
tiated from pleurisy by the diffuse character of the pain, with ab- 
sence of signs denoting effusion and fever and no friction sounds. 
Intercostal Neuralgia is characterized by sharp lancinating 
pain in the side, tenderness at the points of exit of the intercostal 
nerves and the absence of fever and friction sounds. 

Hydrothorax and Pyothorax are best differentiated from pleu- 
risy with effusion, when the fluid is aspirated. Hydrothorax also 
lacks elevation of temperature, absence of pain and is usually 
seen in conjunction with chronic cardiac or renal disease. Pyo- 
thorax shows itself by the characteristic constitutional symptoms 
of sepsis. 

COMPLICATIONS: Croupous Pneumonia frequently occurs 
as a complication with pleurisy, either appearing as the primary 
or secondary disease. If the two diseases develop at about the 
same time, total disability generally lasts longer than when the 
pleurisy is uncomplicated. 

Tuberctdosis of the Lungs is often a complication of pleurisy 
and all cases of this disease with effusion must be carefully inves- 
tigated, and when this is done a great many individuals are found 
to be tuberculous, the pleurisy simply being a manifestation of tu- 
berculosis. Some well knowm authorities claim that almost every 
case of pleurisy is tuberculous in origin. 

HOUSE CONFINEMENT in mild cases of pleurisy In 
which little, if any, effusion has taken place, requires from 2 to 3 
weeks and this time may be prolonged from 3 to 7 davs. when the 
termination occurs during inclement weather. Cases of pleurisy 
with serous effusion cause house confinement in all classes of 



412 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

risks from 3 to 5 weeks. Aspiration in these cases has no bearing 
on the length of house confinement. Pleurisy with effusion which 
becomes purulent requires an operation for removal of the pus 
and house confinement lasts from 4 to 6 or 8 weeks after the 
operation is performed and usually from 2 to 3 weeks have elapsed 
before this procedure is necessary. When pleurisy compHcates 
some other disease of the lungs, house confinement is prolonged 
I to 3 weeks, according to the severity of the complication and 
the primary disease, together with the physical condition of the 
individual at the time the pleurisy develops. 

TOTAL DISABILITY in preferred risks when the duties 
of the occupation are performed inside and the disease is com- 
plicated with little or no effusion, lasts from 2 to 3 weeks. Under 
the same conditions, total disability lasts from 3 to 4 weeks when 
the duties of the occupation are performed in the open air. All 
classes of risks suffering from pleurisy with an effusion, are totally 
disabled from 4 to 6 or 8 weeks; this time depending on the quan- 
tity of the fluid in the chest cavity and the rapidity with which it 
is absorbed and also the number of times aspiration is necessary. 
Cases of pleurisy followed by purulent effusion in preferred risks 
which require an operation, are totally disabled from 6 to 8 or 10 
weeks; the period of disability depending on the amount of pus 
that collects inside the cavity, the date and extent of the operation 
and the exact duties of the occupation. Ordinary risks under the 
same conditions are totally disabled from 2 to 3 or 4 months. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
when payable by the policy in addition to house confinement, re- 
quires from I to 3 or 6 weeks; this time being governed by the 
severity, character and termination of the pleurisy, the physical 
condition of the individual at the ending of the disease and the 
state of weather. 

EFFECTS: Individuals with a history of having suffered 
from pleurisy which was uncomplicated by effusion or any disease 
are insurable for aU kinds of insurance from three to six months 
after complete recovery. If a serious effusion was present, such 
cases are insurable for accident insurance from two to three 
months after recovery, and for life or health insurance from six 
to eight months after complete return to health. When the ef- 
fusion has been purulent and an operation has been performed, 
life or health insurance can seldom be granted until tAvo to three 
years after the date of operation and not even then, until after a 



PLATE X 

FIG. 1. — Anterior Aspect. 




J-1 



M4^ 



FIG. 2.— Posterior Aspect. 




-:>A;; 




ft 



■% 



Pleurisy with EtTusion ^left-sided). 

(Musser) 



PHARYNGITIS 413 

most careful physical examination has been made by a competent 
medical man. Accident insurance, however, in such cases could 
be issued as soon as the individual has apparently recovered from 
the illness, probably from three to six months after the external 
wound had completely healed. 

PHARYNGITIS 

SYNONYMS: Acute pharyngitis; acute catarrhal pharyn- 
gitis; catarrhal tonsilitis; angina catarrhaHs; simple angina; acute 
sore-throat. 

INFORMATION: Acute pharyngitis is a catarrhal inflam- 
mation of the pharynx and the adjacent parts, including the soft 
palate, tonsils and uvula, and is most often caused by exposure, 
but sometimes results from irritants that are swallowed or taken 
into the mouth. It is present in certain infectious diseases, such 
as measles, erysipelas, scarlet fever, diphtheria, smallpox, etc. 

SIGNS AND SYMPTOMS: An attack of this disease fre- 
quently begins suddenly with chilliness, sHght fever, headache, 
thirst, coated tongue, bad taste in the mouth, loss of appetite and 
painful deglutition. A constant desire to clear the throat is ex- 
perienced and tenderness when making pressure on the neck. In- 
spection reveals a red, swollen and inflamed condition of the 
pharynx and surrounding parts. 

DIFFERENTIAL DIAGNOSIS: Diphtheria is diagnosed 
from pharyngitis by the characteristic false membrane, pro- 
nounced prostration and the presence of the Klebs-Loeffler ba- 
cillus. 

Acute Tonsilitis is sometimes mistaken for catarrhal pharyn- 
gitis, but acute cases of the former disease have more marked 
symptoms of systemic involvement, including rapid pulse, higher 
temperature and prostration. 

Retropharyngeal Abscess may simulate an attack of pharyn- 
gitis, but in this condition there is high, irregular fever, with stiff- 
ness of the muscles of the neck and on examination a projection 
is seen inside the pharynx. 

Rheumatic Pharyngitis is diagnosed by the intense pain and 
•difficulty of deglutition, with absence of evidence of inflammation 
of the pharynx. It is usually followed by a manifestation of rheu- 
matism involving some of the muscles. 

COMPLICATIONS: Abscess of the pAir may result from 
acute pharyngitis and when present is duo to the inflammation 



414 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

traveling through the Eustachian tube. Deafness from the same 
cause may also ensue as a complication. 

Laryngitis not infrequentl}^ follows an acute attack of pharyn- 
gitis and is due to the extension downward of the inflammation 
which results in the characteristic signs and symptoms of this 
disease. 

SEQUELAE: The Infectious Fevers often manifest them- 
selves in the beginning by an acute pharyngitis and if any of these 
diseases are present, the length of disability is governed by the 
disease and not by the pharyngitis which is simply a forerunner 
of an illness that is to follow. 

HOUSE CONFINEMENT seldom lasts more than from 3 
to 7 days in acute uncomplicated attacks of pharyngitis. If the 
pharyngitis is the beginning of another disease or is complicated 
by inflammation to surrounding parts, the length of disability is 
controlled by the succeeding disease or complication. 

TOTAL DISABILITY in all classes of risks suffering from 
uncomplicated attacks of pharyngitis, seldom last more than I 
week. If the termination occurs during the winter months, this 
time may be prolonged from i to 3 days. Preferred risks whose 
occupation requires constant use of the voice are sometimes to 
tally disabled from 10 to 14 days, when this inflammation exists 
and a slight involvement of the larynx occurs. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is almost never deserved following this acute inflammation. 

EFFECTS : Individuals suffering from uncomplicated cases 
are insurable for all kinds of insurance as soon as recovery is com- 
plete. Should the inflammation result in an abscess of the middles 
ear, the individual is not insurable for a life poHcy until one to two 
years have elapsed after the abscess has entirely healed and no 
discharge shows itself during this time. Some insurance com- 
panies will issue a health policy from three to six months after the 
discharge from the abscess has entirety ceased; while others re- 
quire from one to two years, the same as for life insurance. Ac- 
cident insurance is sometimes granted irrespective of any dis- 
charge from the ear which may be present. 

CATARRHAL PNEUMONIA 

SYNONYMS: Lobular pneumonia; broncho-pneumonia; 
capillary bronchitis. 



CATARRHAL PNEUMONIA 415 

INFORMATION : , Catarrhal pneumonia is an inflamma- 
tion of the terminal bronchial tubes and surrounding alveoli of 
the lungs. It is more common in children and in the aged and 
most frequently follows from an extension downward of a bron- 
chial catarrh. It is also a sequels of the acute diseases, such as 
la grippe, diphtheria, whooping cough, etc. If pneumonia results 
from a foreign body being drawn into the lungs, it is the catarrhal 
form. Sometimes indemnity is asked under an accident policy 
for catarrhal pneumonia due to a foreign body in the lungs, when 
it is claimed that the pneumonia is the result of this condition 
produced accidentally. Such cases may occur when the sensibility 
of the larynx is impaired for any reason and if this impaired sensi- 
bility is present and permits a foreign body to enter the lungs 
through the bronchial tubes and disability results, indemnity is 
not payable under an accident policy. 

SIGNS AND SYMPTOMS : This disease begins in an in- 
sidious manner, the signs and symptoms being referable to a ca- 
tarrhal bronchitis which generally becomes worse, showing the 
temperature moderately high, running from ioi° to 103° F. ; the 
pulse is irregular and rapid, respirations increased in number, 
with at first a dry cough soon to be followed, however, by expecto- 
ration of muco-purulent matter. Percussion shows scattered 
areas of dullness in both lungs and on auscultation there is heard 
bronchial breathing accompanied by mucous and sub-crepitant 
rales. 

DIFFERENTIAL DIAGNOSIS : Croupous Pneumonia may 
■sometimes be mistaken for catarrhal pneumonia and the points of 
differential diagnosis are pointed out under the former disease. 

Bronchitis is often hard to differentiate from catarrhal pneu- 
monia, but in this disease pain is complained of posterior to the 
sternum, fever is not so high and slight difficulty in breathing ex- 
ists; on percussion, dullness is not found and on auscultation 
hard, bronchial breathing is heard over both lungs in the earlier 
stages. 

Edema of the Lungs should not cause any difficulty in making 
a diagnosis, as edema in this situation is bilateral and is accom- 
panied by cough, expectoration of blood-streaked nutcus, with 
much dyspnea and absence of the vesicular murmur. In addition, 
there is no early history indicating a catarrhal condition and the 
temperature is onl}^ slightly elevated. 

Acute Tuberculpsis begins with a capillary bronchitis and the 
differential diagnosis between this and catarrhal pneumonia is not 



416 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

often made until after the disease has been existing for some time, 
when the course, together with repeated physical and sputum ex- 
aminations, A\dll serve to make the correct diagnosis. 

SEQUELAE: Emphysema of the Lungs sometimes super- 
venes after attacks of catarrhal pneumonia, and in such cases dis- 
ability is prolonged and an impaired risk results. 

Pulmonary Titherciilosis follows catarrhal bronchitis when this 
disease does not end in resolution. When tuberculosis of the 
lungs supervenes, disability is greatly prolonged if death does not 
cause a fatal termination in a short time. 

HOUSE CONFINEMENT lasts from i to 3 weeks in all 
classes of risks suffering from catarrhal pneumonia and this tim.e 
is increased i to 2 weeks when the disease occurs during the win- 
ter and in individuals whose physical condition is debilitated from 
any cause. 

TOTAL DISABILITY in uncomplicated cases of this dis- 
ease and in preferred risks, lasts from i to 3 or 4 weeks; this time 
depending on the season of the year, the age and physical condi- 
tion of the claimant and the exact duties of the occupation. Or- 
dinary risks are usually totally disabled i to 2 weeks longer than 
preferred risks when suffering from an attack of catarrhal pneu- 
monia. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, seldom demands more than i to 2 weeks in all classes of 
risks. 

EFFECTS : When a history of an attack of catarrhal pneu- 
monia exists, the individual is not insurable for a life or health 
policy until one to two years after the termination of the attack 
and a most careful medical examination shows no impairment of 
the lungs. An accident policy, however, may be written from 
three to six months after recovery has been complete. 

CROUPOUS PNEUMONIA 

SYNONYMS: Pneumonia; lobar pneumonia; pneumonitis; 
pleuro-pneumonia; fibrinous pneumonia; lung fever; winter fever. 

INFORMATION: Pneumonia is an acute inflammatory 
condition of one or more lobes of the lungs; the lower right lobe 
being most frequently affected. It occurs more often in men 
than in women, is more common during the winter months and is 
caused by a specific micro-organism, the diplococcus of pneu- 



CROUPOUS PNEUMONIA 



417 



monia as described by Frankel. Predisposing causes are expo- 
sure, alcoholism, lowered vitality, poor hygienic surroundings and 
an existing disease, such as chronic Bright's disease, diabetes or 
some of the infectious fevers. One attack renders an individual 
susceptible to a recurrence of the disease. Pneumonia is one of 
the diseases for which indemnity is payable under a special or 
limited health policy. Aborted cases of pneumonia are those that 
go through the first stage or the stage of congestion only and are 
not covered by this limited policy. 




Fig. 102. — Diplococcus of Pneumonia from rabbit blood. (H. K. Mulford Co.) 

SIGNS AND SYMPTOMS : An attack begins with a severe 
chill followed by a rapid rise of temperature, the fever reaching 
as high as 103° to 105° F. within the first twenty-four hours. This 
elevation of temperature is accompanied by marked dyspnea, shal- 
low, rapid respirations, accelerated pulse and pain in the affected 
part of the lung which is increased by coughing, deep breathing 
and sneezing. The cough at first is dry, followed later by expec- 
toration of bloody, tenacious sputum or ''rusty sputum," as it is 
called. These symptoms continue until the fifth to the eleventh 
day, when the crisis usually takes place by a sudden fall of tem- 
perature and convalescence is- established. On palpation, vocal 



418 



DISEASES OF LUNGS AND RESPIRATORY SYSTEM 



fremitus is increased over the consolidated part of the huig which 
gives a dull note on percussion and on auscultation crepitant rales 
are heard at the end of deep inspirations. 



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Fig. 103. — Temperature, pulse, and respiration curA'e in croupous pneumonia. (Sahli). 

DIFFERENTIAL DIAGNOSIS: Croupous Pnetmionia is 
easily diagnosed from catarrhal pneumonia by means of the fol- 
lowing table from Stevens : 

Croupous Pneumonia Catarrhal Pneumonia 



Usually a primary disease. 



The onset is abrupt and with a 
distinct chill. 

The fever is high, regular, and 
generally ends by crisis be- 
tween the sixth and ninth 
day. 

The sputum is rusty and trans- 
lucent. 



Usually secondary to bron- 
chitis or an acute infectious 
disease. 

The onset is gradual and with- 
out a distinct chill. 

The fever is moderately high, 
very irregular and ends by 
lysis after an indefinite 
period, sometimes of two or 
three weeks' duration. 

The sputum is mucopurulent 
or glairy and tenacious. 



d 



CROUPOUS PNEUMONIA 419 

In the majority of cases only Both lungs are commonly af- 

one lung is affected. fected. 

The physical signs are distinct The physical signs are indis- 

and indicate a large uniform tinct and indicate scattered 

consolidation. areas of consolidation. 

Pleurisy is often mistaken for an attack of croupous pneu- 
monia, but this disease seldom begins with a chill, the tempera- 
ture is not as high, the level of dullness in the chest is change- 
able, which is not the case in pneumonia, the apex beat is dis- 
placed in pneumonia and absent in pleurisy and a friction sound 
accompanies breathing in cases of pleurisy, while bulging of the 
intercostal spaces is not seen in pneumonia and the crepitant 
rale is heard. 

Edema usually occurs in conjunction with another disease 
and begins insidiously; both lungs are affected, which is seldom 
the case in a beginning pneumonia, elevation of temperature and 
pain are absent in this condition, while they are present in pneu- 
monia, expectoration in edema is serous, but is rusty in pneu- 
monia, and auscultation shows weak breathing and sub-crepitant 
rales in edema. 

Acute Pulmonary Tuberculosis is diagnosed by the family, to- 
gether with the personal history, the age and appearance of the 
individual, the character of the sputum which contains shreds of 
lung tissue, the remittent type of fever, night sweats, emaciation, 
and the presence of tubercle bacilli. 

COMPLICATIONS: Endocarditis not infrequently compli- 
cates this disease and in such cases the onset is generally gradual 
with or without chills, the temperature is irregular, pulse also 
irregular and rapid, increased difificulty in breathing and embar- 
rassed cardiac action with precordial pain exist. 

Pleurisy often supervenes and complicates pneumonia, and 
in such cases the signs and symptoms of this disease are noticed 
in addition to those produced by pneumonia. 

HOUSE CONFINEMENT in aborted cases of pneumonia 
and those that terminate in death, lasts- from i to 2 weeks in all 
classes of risks. Ordinary uncomplicated attacks which pursue 
a regular course, require from 2 to 4 weeks of house confinement. 
Severe cases in which the base and apex are involved or a part 
of each lung, require from 3 to 6 weeks. When pneumonia is 
complicated by any other disease, the above time is increased ac- 



-TTS-TTT^rT^T 



420 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

cording to the duration of the comphcation. If an attack of 
pneumonia terminates during exceedingly severe winter weather 
or the occupation of the individual is performed without shelter, 
house confinement is increased i to 2 Aveeks in such cases. 

TOTAL DISABILITY: Aborted cases or those in which 
the first stage of pneumonia is reached and is followed by con- 
valescence, require from i to 2 weeks of total disability, and in 
very severe cases death usualty occurs within this time. Ordi- 
nary cases which terminate by crisis are totally disabled from 2 
to 4 weeks. Individuals suffering from severe attacks of this dis- 
ease in which one or both lungs are more or less involved, are 
totally disabled from 3 to 6 weeks; this time may be prolonged 
I to 2 weeks on account of the severity of the inflammation, ter- 
mination by lysis and weather conditions. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, usually requires from 3 to 7 days in aborted cases; from i 
to 2 weeks in uncompHcated ones that have passed through all 
the stages of the disease and from 2 to 3 weeks in the severe ones 
w^hich leave the individual in a debilitated condition. 

EFFECTS: When an attack of pneumonia occurs during 
the fall or winter, the sufferer is not insurable for life or health 
insurance until the following summer and even then, not until a 
medical examination has been made and the report is satisfac- 
tory. Pneumonia occurring during the summer months, renders 
the individual uninsurable for life or health insurance until the 
ensuing summer. Accident insurance, however, can generally 
be safely written on such individuals from one to two months 
after complete recovery takes place. 

PNEUMOTHORAX 

SYNONYMS: Hydropneumothorax; air in the pleural 
cavity. 

INFORMATION: When air exists in the pleural cavity 
outside of the lungs, it is frequently the result of the perforation 
of the lungs due to tuberculosis and usually follows a violent 
paroxysm of coughing. This condition may also exist from other 
causes which rupture the lung and allow the air to escape into 
the pleural cavity, such as the fractured end of a rib perforating 
the lung, puncture of the chest wall, abscess, gangrene, and in 
rare instances rupture of an emphysematous lung. 



PNEUMOTHORAX 421 

SIGNS AND SYMPTOMS: This condition is usually sud- 
den in onset accompanied by sharp pain in the side, great diffi- 
culty in breathing, subnormal temperature, weak pulse, coldness 
of the extremities, in fact all signs and symptoms of severe shock. 
Inspection shows bulging of the intercostal spaces on the affected 
side with respiratory movements on the same side lessened or 
abolished. Vocal fremitus is diminished and dullness is elicited 
over the effusion when it takes place. Auscultation shows the 
respiratory murmur to be almost inaudible or absent and w^hen 
the fistula is open, amphoric breathing is heard. 

DIFFERENTIAL DIAGNOSIS: Dilitation of the Stomach 
in some cases might be mistaken for this condition, because the 
tympanitic note that is heard on percussion over a pneumothorax 
is also heard over the dilated stomach in the abdomen, and when 
swallowing takes place the passage of the liquid into the stomach 
is readily detected by means of a stethoscope. 

COMPLICATIONS: Hemothorax or blood in the pleural 
cavity usually complicates pneumothorax. If this condition ex- 
ists after an accidental puncture of the chest wall, it may result in 
uncontrollable bleeding which ends in death. 

Hydrothorax accompanies a pneumothorax and is distin- 
guished by the signs and symptoms described above. Disability 
is not often prolonged by this complication. 

HOUSE CONFINEMENT is generally existing when a 
pneumothorax occurs; the individual being already a sufferer 
from tuberculosis of the lungs and this condition is one of the 
later complications. If the pneumothorax results from a punc- 
tured wound of the chest or the fractured end of a rib perforates 
the lung, house confinement lasts from 2 to 4 weeks according 
to the cause, and also the treatment. 

TOTAL DISABILITY in cases of pneumothorax which re- 
sult from accidental punctures of the lung by the fractured end 
of a rib, lasts from 2 to 4 weeks in preferred risks. Under the 
same conditions, ordinary risks are totally disabled from 4 to 6 
and sometimes 8 weeks. If the pneumothorax is due to a punc- 
ture of the chest wall, an operation is generally performed shortly 
after the puncture occurs, when total disability lasts from 4 to 6 
weeks in preferred risks and from 6 to 8 weeks in ordinary ones. 
If the condition occurs during the progress of a case of tubercu- 
losis of the lungs, total disability is already existing in the ma- 



422 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

jority of cases and this complication simply aggravates the phy- 
sical condition of the individual. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is sometimes allowable to preferred risks, when from i to 
3 weeks are sufficient in the majority of cases. 

EFFECTS: Individuals having suffered from a pneumo- 
thorax produced accidentally, in which the lungs were normal 
before the accident and where recovery becomes complete with- 
out an operation, are not insurable for a life or health policy un- 
til at least one year after complete recovery takes place. If an 
operation is necessary for the cure of this condition, a life or 
health policy would not be issued until at least three to five years 
had elapsed without any symptoms referable to the chest as the 
result of the accident and operation. Accident insurance, how- 
ever, in both cases can usually be safely written from three 
to six months after the ending of disability. If pneumothorax 
occurs from any other cause, life or health insurance, would hardly 
be considered by any insurance company until five to ten years 
after recovery had been pronounced complete. 

ACUTE TONSILITIS 

SYNONYMS: Tonsilitis; follicular tonsiHtis; amygdalitis; 
quinsy; suppurative tonsilitis; phlegmonous pharyngitis. 

INFORMATION: TonsiHtis is an acute inflammation of 
the tonsils, involving one or both and occurring at all ages, but 
more common from twenty to thirty years and is caused by ex- 
posure, although a predisposition for this disease apparently ex- 
ists in those of a rheumatic tendency. The majority of these 
cases are usually follicular tonsilitis and Avlien the inflammation 
goes on to suppuration, the phlegmonous form develops. 

SIGNS AND SYMPTOMS: An attack of this disease be- 
gins with a chill or chilHness followed by a rapid rise of tempera- 
ture reaching 102° to 104° F, and is accompanied by accelerated 
pulse, headache, painful deglutition with swelling of the lymphatic 
glands and tenderness at the angle of the jaws. Examination of 
the throat shows the tonsils swollen and inflamed and in the fol- 
licular form, small yellow spots are scattered over the surfaces. 
In the phlegmonous variety, the tonsils are so greatly swollen 
that in some cases they almost touch each other. Intense, throb- 



ACUTE TONSILITIS 



423 



bing pain is present and as the gland goes on to suppuration, it 
becomes soft and fluctuating and at the point which is about to 
rupture, a yellowish spot appears. 

DIFFERENTIAL DIAGNOSIS: Diphtheria in the early 
stages may sometimes be mistaken and diagnosed as acute ton- 
silitis, but in this disease there soon forms a false membrane that 
leaves a raw, bleeding surface when it is detached and a culture 
from this membrane shows the Klebs-Loeffler bacillus. 

Scarlet Fever almost invariably commences with an inflam- 
mation of the larynx, including the tonsils. In this disease the 
strawberry tongue is a characteristic point of diagnosis and 




Fig. 104,' — Enlarged faucial tonsils; the tonsils shows a large crypt. (Kyle). 



within twenty-four to thirty-six hours the peculiar punctiform 
eruption of scarlet fever appears. 

COMPLICATIONS: Abscess of the Middle Ear may follow 
this inflammation and be due to infection which travels through 
the Eustachian tube. If this complication arises, disability is pro- 
longed according to the time required for abscess of the ear. 

Congestion of the Kidneys frequently follows an attack of 
acute tonsilitis. If this complication ensues, total disabilitv is 
prolonged according to the time required for the congestion to 
subside and the kidneys to become normal again. 

HOUSE CONFINEMENT in all classo^s of risks sufferino- 

o 

from acute follicular tonsilitis lasts from :; to 7 davs. \Mien the 



424 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

inflammation goes on to suppuration and quinsy results, house 
confinement lasts from i to 2 weeks. If the inflammation ter- 
minates in recovery during inclement weather, house confine- 
ment is prolonged from i to 3 or 5 days under either of the 
above varieties. 

TOTAL DISABILITY in all classes of risks usually lasts i 
week when foUicular tonsilitis has been the cause. If this form 
results in suppurative tonsilitis, total disabiHty lasts from i to 2 
weeks. In preferred risks whose occupation requires constant 
use of the voice, this period of disability may be increased 5 to ro 
days, on account of the duties of the occupation and also when 
the termination occurs during damp, winter weather. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
merit, is rarely necessary and when demanded from 2 to 5 days 
are .generally sufficient. 

EFFECTS : Individuals having suffered from one or more 
attacks of acute tonsilitis are insurable for a life or accident policy 
one to two months after complete recovery from the attack. 
Health insurance, however, would not be issued to such persons 
until one to two months after recovery and not unless a waiver 
eliminating indemnity for disability from this disease was placed 
on the policy. 

PULMONARY TUBERCULOSIS 

SYNONYMS: Consumption; pulmonary consumption; tu- 
berculosis; incipient phthisis; phthisis; phthisis pulmonalis; 
chronic phthisis; chronic ulcerative phthisis. 

INFORMATION : Pulmonary tuberculosis is a chronic 
disease of the lungs that is caused by the bacillus of tuberculosis 
gaining access to the lung tissue where it multiplies and causes 
systemic signs and symptoms. It is more common in early adult 
life and in individuals with a hereditary history of the disease in 
the family. Certain occupations, such as those in which dust or 
irritating vapors are constantly inhaled, living in unsanitary sur- 
roundings and a lowered vitality are predisposing causes. 

SIGNS AND SYMPTOMS: This disease is insidious in 
onset, usually beginning with a cold that persists and resists the 
ordinary home treatments. It is accompanied or followed by in- 
digestion, gradual loss of weight, cough which is referred to as 
coming from the throat with slight, if any, expectoration, irritable 



PLATE XI 



- ^^ ] \ .1. H . \ 




Tubercle Bacilli in Sputum. 

A. Showing tubercle bacilli inside the leukocytes (phagocytosis). 

B. Tubercle bacilli outside the leukocytes. 

(H. K. Mulford Co.) 



PULMONARY TUBERCULOSIS 425 

disposition, loss of color in the face and sometimes hemoptysis, 
although this is generally a late sign of the affection. As the dis- 
ease advances, the cough becomes more free, expectoration more 
profuse and the expectorated matter contains shreds of lung tis- 
sue and the tubercle bacilli. Elevation of temperature in the af- 
ternoons and evenings with a subnormal temperature in the early 
morning hours is a characteristic sign, the pulse is increased in 
rapidity and pain in the lungs is complained of, night sweats oc- 
cur regularly and emaciation follows. Inspection shows a de- 
pression over the apices of the lungs, — when involved, — vocal 
fremitus is slightly increased on palpation, and on percussion im- 
paired resonance is eHcited and in time the percussion note be- 
comes dull over consolidated areas and tympanitic over cavities. 
Auscultation shows slightly prolonged expiration with bronchial 
breathing accompanied by crackling and subcrepitant rales which 
are heard at the termination of inspiration and expiration. 

DIFFERENTIAL DIAGNOSIS: The early diagnosis of 
this disease is highly important and should be made by means of 
the history and the physical signs and symptoms. The diagnosis 
is generally made too late for a cure of the disease, when it is 
not made until the bacilli appears in the sputum. Among the 
early signs and symptoms of the disease is a history of persistent 
dyspepsia and slight cough with little or no expectoration in the 
morning. On inspection, the pupils are found widely dilated even 
in the brightest light, the pulse is accelerated, the rate being 
above the normal and usually it is of lowered tension. Slight ele- 
vation of temperature in the afternoons and evenings, with a 
subnormal stage late at night or in the early morning hours is 
pathognomonic. The vagus reflex as described by Dr. Mays, 
of Philadelphia, is said to be one of the early signs. A careful 
examination of the lungs will show impaired resonance over the 
area involved and on auscultation, the expiratory murmur is pro- 
longed and the pitch is raised. 

Acute Miliary Tubernilosis is often mistaken for typhoid 
fever, but in this latter disease epitaxis is common and a roseola 
eruption is present, the Widal reaction is usually obtainable- 
while the temperature runs the characteristic course and none of 
these are present in cases of miliary tuberculosis. 

COMPLICATIONS are so varied and involve so many dif- 
ferent parts of the body that it would. not be feasible to attempt 
to describe each one separateh^ Involvement of the covering of 
the brain, of the alimentarv tract or some of the oroans in con- 



426 DISEASES OF LUNGS ANB RESPIRATORY SYSTEM 

nection with it, of the joints, especially the larger ones and the 
genital organs, are some of the parts which may be affected and 
complicate acute tuberculosis of the lungs. 

HOUSE CONFINEMENT lasts from 3 to 6 or 8 weeks in 
cases of acute miliar}^ tuberculosis; this being at the termination 
of the disease. Ordinary cases of tuberculosis of the lungs which 
have been diagnosed after more or less partial disability, some- 
times require from 2 to 4 or 6 weeks of house confinement, at the 
end of which time modern treatment demands that the individual 
live in the open air all the time. If this treatment is not success- 
ful and recovery does not take place, house confinement of from 
2 to 6 or 8 weeks again ensues and marks the end of the life of 
the individual. Fibroid phthisis seldom requires house confine- 
ment until the termination of the disease is reached, when from 
I to 2 or 3 months and sometimes longer may be necessary in 
these cases. 

TOTAL DISABILITY in cases of acute miliary tubercu- 
losis lasts from 3 to 12 weeks; the usual time being from 6 to 8 
weeks only Ordinary cases of tuberculosis are usually totally 
disabled from 2 to 4 weeks before house confinement ensues and 
this period is prolonged by the time required in the house and 
also the time necessary for a partial or complete cure of the dis- 
ease; this latter ranging from 2 to 6 or 12 months. AVhen total 
disability takes place at the termination of this disease, from 3 
to 6 or 10 weeks are usually sufificient to cover the time from 
the ending of attention to business until death ensues. Fibroid 
phthisis being a chronic disease, seldom causes total disability 
until the termination, this beginning from i to 3 or 4 weeks be- 
fore house confinement commences and persisting during that 
period, finally ending in the death of the individual. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, may last from i to 6 months or more; this time depending 
on the extent of the disease, the physical and financial condition 
of the individual and the treatment. 

EFFECTS : AVhen an individual has once suffered from 
pulmonar}^ tuberculosis, even in a mild form, insurance of all 
kinds must be denied until four to six years have elapsed after 
complete recovery has ensued and no signs or symptoms of the 
disease have manifested themselves within that period. Som.e 
insurance companies would issue accident policies on cases of 
tuberc.ulosis that have been reported cured from one to two or 



WHOOPING COUGH 427 

three years after the date of recovery, but it is questionable if 
such is good underwriting. The majority of companies dechne to 
issue any kind of insurance at any time on any one who has been 
aflflicted with tuberculosis and' a cure reported. 

WHOOPING COUGH 

SYNONYMS: Pertussis; hooping cough. 

INFORMATION: Whooping cough is a paroxysmal, con- 
tagious disease, most common in childhood, although sometimes 
seen in adult life. One attack confers immunity which usually 
persists during the life of the individual. 

SIGNS AND SYMPTOMS of this disease are divided into 
three stages, the catarrhal, paroxysmal and the terminal. The 
catarrhal stage begins with symptoms of catarrh of the naso- 
pharnyx accompanied by sneezing, discharge from the nose, 
slight fever and cough, and lasts from one to two weeks. The 
second stage then follows and is characterized by persistent, hard 
coughing which often causes vomiting and ends with a long deep 
crowing inspiration or whoop. The terminal stage is marked by 
long intervals between the paroxysms which are shorter and less 
violent until finally after one to two wxeks they cease entirely. 

DIFFERENTIAL DIAGNOSIS: Whooping Cough 'is al- 
most impossible to diagnose from an ordinary cold in the ca- 
tarrhal stage, but as soon as the paroxysms occur, the diagnosis 
is readily made. 

SEQUELAE: Meningeal Hemorrhages are sometimes pro- 
duced by violent paroxysms of coughing in an individual who is 
advanced in years. In such cases the usual signs and symptoms 
of pressure on the brain follows and the length of disability is in- 
creased according to the complication. 

Emphysema or collapse of the lung may complicate or follow 
violent paroxysms of this disease; in such cases disability is pro- 
longed, the duration of disability being governed by the compli- 
cation or sequelae. 

HOUSE CONFINEMENT does not exist when whooping 
cough occurs in adults during the spring, summer or fall months, 
but if the disease is contracted during the winter, house confine- 
ment of from I to 2 or 3 weeks may be necessary when the indi- 
vidual is advanced in years or complications ensue. 

TOTAL DISABILITY is seldom present when this disease 
does not cause house confinement, unless it is nocessarv to 



.^^«l..JL 



428 DISEASES OF LUNGS AND RESPIRATORY SYSTEM 

change climates for the cure of the malady, when from 2 to 4 
weeks are generally ample. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
meat, if present, may last from i to 2 or 3 weeks in severe cases 
without regard to the season of the 3^ear. 

EFFECTS : When whooping cough occurs in adults and 
complete recovery ensues without any complications, the indi- 
vidual is insurable for all kinds of insurance two to four months 
after the termination of the disease. Should a hemorrhage within 
the skull occur from the violent paroxysms of coughing, all 
forms of insurance would be denied the person on account of this 
complication. If the lungs are distended or injured in any way 
by the paroxysms of coughing, life or health insurance would not 
be issued until one to two years after the termination of the dis- 
ease and the complication, and a medical examination has shown 
the lungs to have again become normal. Accident insurance in 
such cases, however, could be safely granted from four to six 
months after the termination of disabihty. 



PLATE XII 




Quadrants of the Abdomen. Position of the Viscera. 

Liver and colon— red lines. Stomach, kidneys and bladder— solid green 
Pancreas -dotted green lines. 

(Musser.) 



lines. ! 



CHAPTER XVI 

DISEASES OF THE DIGESTIVE SYSTEM 
APPENDICITIS 

SYNONYMS: Typhlitis; perityphlitis; perityphlitic ab- 
scess; pericaecal abscess; iliac abscess; suppurative appendicitis. 

INFORMATION: Appendicitis is an inflammation of the 
appendix vermiformis and is caused by a variety of germs, the 
chief of which are Ihe bacilli coli communis acting on the lining 
membrane of the appendix that has been abraded or rendered 
susceptible to the action of these germs by a foreign body within, 
traumatism or errors in diet leading to intestinal catarrh. It is 
more common in the male than in the female and is most fre- 
quently seen between the ages of ten and thirty years. 

SIGNS AND SYMPTOMS: An attack of appendicitis be- 
gins with a feeling of weight and soreness in the right iliac region 
and this is soon followed by severe pain, nausea and vomiting. 
Swelling appears in this situation, rigidity of the abdominal walls 
occurs, the pulse is accelerated and the temperature ranges from 
100° to 103° or 104° F. If the attack results in suppurative ap- 
pendicitis, hectic symptoms appear and unless an operation is 
performed, death generally results, although sometimes the ab- 
scess breaks externally or into the bowel or vagina and escapes. 

DIFFERENTIAL DIAGNOSIS: Diseases of the Ovaries 
and Fallopian Tubes are sometimes mistaken for appendicitis, but 
if a careful history of the trouble is secured, together with a bi- 
manual examination, such an error should not often occur. 

Cholecystitis is marked by pain and tenderness over the re- 
gion of the gall-bladder in the right hypochondrium. In this af- 
fection, the cystic duct is obstructed and sometimes the swollen 
gall-bladder is palpable. A history of the passage of gall stones 
would help to distinguish this condition from an attack of appen- 
dicitis. 

Renal Colic is characterized by pain in the loins and some- 
times in the iliac region. When this condition is present, pres- 
sure over the region of the kidneys causes increased pain; there 

429 



iJU J 1 



430 DISEASES OF THE DIGESTIVE SYSTEM 



is frequency of micturition, the urine is albuminous and some 
times hematuria is present. During an attack of renal colic, 
sharp, lancinating pain is present in the back and loins and this 
position of the pain is not complained of- in an attack of appendi- 
citis. 

TypJioid Fever is not infrequenth^^ mistaken for an attack of 
appendicitis. In typhoid fever, however, there is epistaxis, en- 
largement of the spleen, the characteristic rash and temperature 
curve, while the blood usually gives the Widal reaction. 

Hip Joint Disease may be mistaken for appendicitis, but in 
the former, especially if the right hip is involved, it cannot be 
extended under ether, while in appendicitis, flexion is easily 
overcome when unconsciousness is produced. 

Acute Tuhercidoiis Peritonitis is sometimes diagnosed when 
a perforation of the appendix exists. In tuberculous peritonitis 
evidence of the disease is usually present in some other part of 
the body, it is more gradual in onset and swelling of the abdomen 
with tension is absent. 

Ptomaine Poisoning may cause an error in diagnosis, but in 
the former the pain is diffuse, extending over the entire abdo- 
men, diarrhea is present and nervous symptoms follow. The 
heart may become suddenly involved and death ensue. 

COMPLICATIONS: Diffuse Peritonitis always follows an 
attack of appendicitis when infection of the peritoneal cavity oc- 
curs. If this complication is present, death almost invariably ter- 
minates the case in a short time. 

Typhoid Fever occasionally complicates or is compHcated by 
an attack of appendicitis. In such cases if the appendix is re- 
moved during the progress of typhoid fever, — and recovery takes 
place, — the prolonged disability is the result of the fever and not 
the appendicitis. 

Suppurative or Gangrenous Appendicitis or the formation of 
an abscess around the appendix results in an operation at once 
and also the prolongation of disability. 

HOUSE CONFINEMENT of from 7 to 10 days is usually 
necessary in cases of catarrhal appendicitis which are not treated 
by an operation. When this is performed, house confinement 
lasts from 3 to 6 weeks; this time depending on the physical con- 
dition of the individual and also the views of the surgeon as to 
the method of treatment. If on operating an abscess cavity is 



§ 



CHOLERA MORBUS 431 

found and healing by grantilation is necessary, house confine- 
ment may last from 6 or 8 weeks. 

TOTAL DISABILITY in uncomplicated cases of catarrhal 
appendicitis which are not treated by operation require from i 
to 2 weeks. Operative cases in which an inflammatory condition 
only is found at the time the operation is performed, are totally 
disabled from 3 to 6 weeks. When pus has formed and an opera- 
tion is necessary for the removal of the same total disability lasts 
from 6 to ID weeks, beginning with the date of operation and this 
time may have been preceded by from 3 to 7 or 10 days of total 
disability. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, should not require more than from 2 to 5 days in the ca- 
tarrhal form. Uncomplicated cases which have been operated 
upon, sometimes demand from i to 2 weeks of this form of dis- 
ability and when an abscess has been present, from 2 to 4 weeks 
may be necessary after the termination of house confinement be- 
fore some of the duties of the occupation can be resumed. 

EFFECTS : Individuals with a history of having suffered an 
attack of appendicitis are not insurable for a life or health policy 
until three to five years have elapsed without any signs or symp- 
toms of the disease, unless an operation has been performed and 
the appendix removed, when life or health insurance can be writ- 
ten from four to eight months after complete recovery. Should 
such a history be present, health insurance can be written by at- 
taching a waiver to the policy eliminating indemnity for disability 
caused by this disease or any complication. A history of this dis- 
ease has no bearing on the issuance of an accident policy. If an 
operation has been performed, insurance companies generally 
place a waiver on a health policy eliminating indemnity for dis- 
ability due to a hernia and this applies also to a life policy, unless 
the individual agrees to wear a truss, if such a procedure becomes 
necessary. A waiver regarding a hernia is especially necessary 
on persons who are fifty years of age or over. 

CHOLERA MORBUS 

SYNONYMS: Bilious cholera; sporadic cholera: English 
cholera; cholera Nostras. 

INFORMATION: Cholera morbus is an acute catarrhal 
inflammation of the mucous membrane of the stomach and in- 



rsaes^SKF 



432 DISEASES OF THE DIGESTIVE SYSTEM 

testines; it is more common in summer and is due to the inges- 
tion of irritating food and sudden clianges of temperature. 

SIGNS AND SYMPTOMS: An attack of this disease is 
sudden in onset, beginning with cramps in the stomach and fol- 
lowed by nausea, vomiting and purging with intense thirst, fever 
and prostration which becomes marked in severe attacks. The 
duration of these symptoms is usually from twenty-four to thirty- 
six hours except in extreme cases w^hen they may persist for 
one to three days. Death seldom occurs, as the mortality is said 
to be only five per cent. 

DIFFERENTIAL DIAGNOSIS: Poisoning by intent 
should always be held in mind when a claim is received alleging 
cholera morbus as the cause of disability. In such cases, a his- 
tory of financial embarrassment and melancholia due to family 
troubles or illness can almost invariably be secured when a min- 
eral poison has been taken by intent. In addition, evidence of 
the poisoning may be found on the face, lips or in the mouth and 
a burning pain is complained of in these parts; this extending to 
the stomach, intestines and rectum. Vomiting when present is 
extremely painful and the ejected matter contains blood stained 
mucus or blood with shreds of mucous membrane from the 
stomach and esophagus. Purging follows, the stools being 
bloody and in some poisons the drug can be detected in the dis- 
charges. When disability results from poisons taken intention- 
ally, accident or health insurance policies do not cover such cases. 
If it can be positively proven that the poison has been taken ac- 
cidentally, an insurance company would be liable under an acci- 
dent policy for the resulting disabihty and the same is true under 
a general disability policy. 

Asiatic CJwIera occurs after exposure, lacks a history of die- 
tetic excesses and is best diagnosed by the characteristic ''rice- 
water" stools, together with the presence of Koch's comma- 
bacillus. 

HOUSE CONFINEMENT in ordinary attacks of this dis- 
ease does not often last more than i to 2 days. When very se- 
vere, from 3 to 5 days may sometimes be necessary, at the end of 
this time the individual although weak and emaciated, is able to 
go outside. 

TOTAL DISABILITY seldom lasts more than from 2 to 4 
days and unless a health policy pays for disability under one 
week, such cases are not entitled to indemnitv. Sometimes i 



ACUTE DYSENTERY 433 

week is necessary for exceedingly severe attacks of this disease, 
when the individual is so weakened by the constant diarrhea that 
a return to business is impossible under that time. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, almost never requires more than from 2 to 5 days. 

EFFECTS : Insurable for all kinds of insurance as soon as 
recovery is complete. 

ACUTE DYSENTERY 

SYNONYMS: Catarrhal dysentery; amebic dysentery; ba- 
cillary dysentery; colitis; ulcerative colitis; bloody flux. 

INFORMATION: Colitis is an acute inflammation of the 
mucous membrane lining the large intestines. It occurs in the 
temperate zone most frequently in the catarrhal form, while in 
the tropics, the amebic form is most common. Dysentery of the 
catarrhal type is more often contracted during warm weather and 
is caused by the ingestion of irritating food, exposure and poor 
hygienic surroundings. The amebic form is caused by a micro- 
organism and is frequently followed by abscesses of the liver. 

SIGNS AND SYMPTOMS: This disease usually begins 
gradually with loss of appetite, nausea, diarrhea and moderate 
fever running from ioo° to 102° F, abdominal tenderness, with 
pain in the rectum and a constant desire to defecate. The stools 
at first contain fecal matter, but within twenty-four to thirty-six 
hours they become mucus in character with blood and pus. The 
duration of catarrhal dysentery is from one to two weeks, al- 
though sometimes it becomes chronic and the diarrhea persists 
for some weeks. Amebic dysentery is marked with less tenes- 
mus and the stools are alive with the living organism. The dura- 
tion of this form is from eight to ten weeks and twenty per cent. 
of the cases are claimed to be complicated by an abscess of the 
liver. 

DIFFERENTIAL DIAGNOSIS : Acufe Catarrhal Enteritis 
is differentiated from dysentery by the presence of undigested 
food in the stools and the absence of blood. Some cases of this 
disease are accompanied by an abdominal eruption resembling 
that of typhoid fever. Tenesmus is less marked in enteritis than 
in dysentery. 

COMPLICATIONS: Peritonitis from extension of the in- 
28 



434 DISEASES OF THE DIGESTIVE SYSTEM 

flammation involving the colon or the result of a perforation of 
an ulcer sometimes follows or complicates an attack of dysen- 
tery, when the period of disability, — if recovery takes place, — 
will be governed by the complication. 

Hepatic Abscess is the most common complication of dysen- 
tery and generally follows the amebic form, being more common 
in the tropics. When an abscess of the liver results, disability is 
greatly prolonged. 

HOUSE CONFINEMENT in all classes of risks in an or- 
dinary attack of catarrhal dysentery generally lasts about i 
week. When the amebic form occurs, house confinement of from 
4 to 8 weeks and sometimes longer is necessary. 

TOTAL DISABILITY in preferred risks suffering from 
catarrhal dysentery lasts from 2 to 3 weeks when house confine- 
ment of one week has existed. Ordinary risks are totally dis- 
abled from 3 to 7 days longer than preferred risks under the 
same conditions. Amebic dysentery causes total disability of 
from 6 to 12 weeks and this_ time is increased for an indefinite 
period, often running beyond the limit of the policy when an 
abscess of the liver develops and requires an operation. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, lasts from i to 2 weeks in preferred risks and from 2 to 3 
weeks in ordinary ones, w^hen an attack of catarrhal dysentery of 
average duration has been suffered. 

EFFECTS : Individuals suffering from an attack of ca- 
tarrhal dysentery of average duration, are insurable for all kinds 
of insurance from three to six months after complete recovery. 
If complications have been present with the attack, each case 
must be considered by itself, when life or health insurance will 
not be granted until after a longer time than the above. Acci- 
dent insurance, however, in almost every case with a history of 
this disease can be issued as early as one month after the termi- 
nation of the attack. When a history of amebic dysentery is ob- 
tainable life or health insurance would not be written until at 
least three to five years after the attack and an abscess of the 
liver or lungs had not supervened. It is questionable if accident 
insurance in such cases could be safely written until a year or 
more after complete recovery. 



CATARRHAL ENTERITIS 435 

CATARRHAL ENTERITIS 

SYNONYMS: Diarrhea; intestinal catarrh; inflammation 
of the bowels. 

INFORMATION: Catarrhal enteritis is an acute inflam- 
mation of the mucous mem.brane of the small intestines. It is 
more common in children and during warm weather and is due 
to irritants which are swallowed, such as impure water, tainted 
meats, mineral poisons and toxins produced by the decomposi- 
tion of foods. 

SIGNS AND SYMPTOMS : Acute catarrhal enteritis com- 
mences with slight fever accompanied by pain and tenderness in 
the abdomen, and diarrhea, the stools being yellowish-green in 
color, offensive and mixed with undigested food. When the 
diarrhea becomes excessive the discharges contain no blood, but 
are known as ''rice-water" stools. Weakness and emaciation fol- 
low excessive evacuations from the bowels; sometimes an abdom- 
inal eruption resembling that seen in typhoid fever is met with 
in these cases. The acute form of this disease may become 
chronic, in which event the diarrhea persists for a variable 
length of time. 

DIFFERENTIAL DIAGNOSIS : Perifoniiis should not be 
mistaken for intestinal catarrh, as this inflammation is not accom- 
panied by diarrhea, but instead constipation is present, the ab- 
domen is swollen and tympanitic, the patient lies on the back with 
the knees elevated, severe pain is present and the constitutional 
symptoms serve to indicate the disease. 

Typhoid Fever in the early stage might be diagnosed for this 
acute disease, but this fever is preceded by prodromes, such as 
malaise, nose bleeding, headache, etc., the spleen becomes en- 
larged, rose spots appear and the characteristic temperature curve 
is present, together with the Widal blood reaction: all of the 
above being absent in catarrhal enteritis. 

Dysentery is differentiated from diarrhea by the severe tenes- 
mus, prostration, blood and mucus in the stools. 

Ileocolitis is marked by more pronounced symptoms, such as 
tenderness and distention of the abdomen, high fever, rapid loss 
of weight, great prostration, with blood and mucus in greenish- 
yellow discharges. 

HOUSE CONFINEMENT in mild cases in adults seldom 
lasts more than 3 to 5 days. If the attack lias boon very severe. 



T^mmm 



436 DISEASES OF THE DIGESTIVE SYSTEM 

house confinement of from 7 to lo days may be necessary in all 
classes of risks. 

TOTAL DISABILITY of from 3 to 7 days is generally re- 
quired by adults when a mild attack of intestinal catarrh occurs. 
If the diarrhea has been severe and much weakness and emacia- 
tion results, total disability of from 7 to 14 days may be required. 
Under the majority of industrial health policies, total disability 
with house confinement of seven days is necessary before the 
individual has a claim. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, may last from 3 to 7 days; this time being required on ac- 
count of weakness and debility from the constant discharges from 
the bowels. 

EFFECTS : Individuals suffering from an attack of ca- 
tarrhal enteritis are insurable for all kinds of insurance from three 
to six weeks after recovery is complete. 

DIARRHEA 

SYNONYMS: Enterorrhea; purging; alvine flux. 

INFORMATION: Diarrhea is an acute condition which 
is usually a symptom of some other trouble. It results from a 
number of causes, such as an inflammation involving some part 
of the intestines, the ingestion of impure food and Hquids, irri- 
tants taken into the stomach, such as poisons or foreign bodies 
and also follows the taking of cathartics. It is a symptom in cer- 
tain diseases like typhoid fever, tuberculosis of the intestines 
and some of the tropical infections. 

SIGNS AND SYMPTOMS: Acute diarrhea begins with 
pain in the abdomen w^hich is distended by gas, and sometimes 
nausea with frequent evacuations of the bowels. These at first 
contain fecal matter and are offensive, but later consist only of 
liquids. Chronic diarrhea sometimes supervenes after an acute 
attack when the above signs and symptoms are present, together 
with weakness, emaciation and anemia. 

DIFFERENTIAL DIAGNOSIS is important when diar- 
rhea is existing and an insurance policy is carried by the indi- 
vidual. If the frequent discharges are due to local irritation and 
recovery soon takes place, it has no bearing on the desirabihty 
of the risk, but if the diarrhea is due to a svstemic condition, such 



GASTRALGIA 437 

as typhoid fever or is caused by tuberculosis of the intestines, it 
is highly important that the proper diagnosis be made. Insur- 
ance companies would not knowingly carry an individual who had 
suffered an attack of tuberculous diarrhea. 

HOUSE CONFINEMENT does not often last more than 
from I to 3 days when the diarrhea is checked and the usual oc- 
cupation resumed. If the condition is intractable and a chronic 
diarrhea results, house confinement of i to 2 weeks may follow 
on account of the weakened condition of the individual from the 
excessive evacuations of the bowels. 

TOTAL DISABILITY seldom lasts over 2 to 3 days when 
an acute attack of diarrhea occurs and unless the policy pays for 
disability under seven days and house confinement is not neces- 
sary, such a person can haA^e no claim against an insurance com- 
pany. Chronic diarrhea may cause total disability of from i to 
3 or 4 weeks in individuals who are not robust and whose oc- 
cupation requires more or less manual labor. If this condition 
is due to a systemic disease like typhoid fever or tuberculosis, 
disability is controlled by the disease and not by the symptom. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is almost never claimed after cases of acute diarrhea, but 
when the disease becomes chronic and house confinement does 
not exist, from i to 2 or 3 weeks of this form of disability may 
be necessary in such cases. 

EFFECTS : Individuals suffering from acute diarrjiea are 
insurable for all kinds of insurance as soon as recovery takes 
place, but when the condition becomes chronic and persists for 
several weeks or months, life or health insurance would not be 
issued on such a person until three to six months after cessation 
of the excessive discharges and the individual has made a com- 
plete recovery. Accident insurance in such cases could be 
granted a short time after the diarrhea ceased. 

GASTRALGIA 

SYNONYMS: Gastrodynia; cardialgia; neuralgia of the 
stomach; stomach colic; spasm of the stomach. 

INFORMATION : Gastralgia is a painful condition of the 
nerves of the stomach, the pain resembling that of neuralgia. It 
is more common in women and results from a number of causes, 



^m 



438 DISEASES OF THE DIGESTIVE SYSTEM 

among which may be mentioned reflex irritations, sexual ex- 
cesses and mental overwork and worry. It is a common compli- 
cation of certain diseases, such as cancer or ulcer of the stomach, 
neurasthenia and certain diseases resulting from uric acid dia- 
thesis. 

SIGNS AND SY]\IPTO]\IS occur suddenly and consist of 
severe paroxysms of pain in the stomach which radiate to the 
chest and back. These paroxysms occur at irregular intervals 
and last from a few minutes to several hours, being accompanied 
by a feeling of faintness, cold extremities and intermittent pulse. 
Pressure over the abdomen or the taking of food sometimes 
relieves this condition. 

DIFFERENTIAL DIAGNOSIS: Angina Pectoris might 
be mistaken for gastralgia, but in . this disease the paroxysms 
usually come on at night, the pain being referable to the heart 
and radiating from that point to the neck and arm, rigidity of the 
body occurs and great fear of impending death is present. Ar- 
terio-sclerosis is usually found when attacks of angina pectoris 
occur. 

Intercostal Neuralgia is characterized by pain along the inter- 
costal nerves with spots of tenderness and in many cases the de- 
velopment of herpes over the inflamed nerve or nerves. Nausea 
and vomiting or symptoms referable to the stomach are absent 
in uncomplicated cases of intercostal neuralgia. 

Gastric Cancer is manifested by pain, which is usually con- 
tinuous and is aggravated by the swallowing of foods. The age 
of the patient together with the presence of perhaps a palpable 
tumor with more or less vomiting, hematem_esis, emaciation and 
lactic-acid fermentation serve to make the diagnosis clear. 

Gastric Ulcer is associated with localized, constant pain which 
is .aggravated by the taking of food and sometimes relieved by 
vomiting, tenderness on pressure over the location of the ulcer 
and hematemesis exists. 

Biliary Colic produces severe pain located in the right hypo- 
chondriac region and radiating to the right shoulder and scapula. 
This pain is often accompanied by fever and jaundice and some- 
times the gall-bladder exists as a distinct tumor. 

Renal Colic is characterized by intense shooting pains lo- 
cated over the affected kidney and following the ureter on the 
side involved; blood, mucus and particles of concretions are found 
in the urine. 



ACUTE GASTRIC CATARRH 439 

COMPLICATIONS: Gastralgia often exists as a compli- 
cation of some other disease and when found in this connection, 
disability is governed by the more important affection. 

HOUSE CONFINEMENT in all classes of risks usually 
lasts from 2 to 4 days only, unless the attacks are of long dura- 
tion and occur at short intervals, when from 5 to 7 days confine- 
ment to the house and sometimes to the bed may be necessary 
before the condition is controlled. 

TOTAL DISABILITY of from 2 to 4 days is usually neces- 
sary in attacks of gastralgia in all classes of risks unless frequent 
attacks have occurred at short intervals and house confinement 
of from 3 to 7 days has existed, when total disability may last i 
week. Claims of over one week's duration for uncomplicated 
gastralgia seldom occur and if such a claim is made, the condition 
is usually compHcated by some existing disease which would ren- 
der the individual uninsurable. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is rarely necessary. 

EFFECTS : Individuals having suffered from one or more 
attacks of gastralgia which have been uncomplicated by any or- 
ganic disease, are insurable for a life policy at almost any time, 
provided all other conditions are favorable. A health policy, 
however, would not be written with a history of repeated attacks 
of this disease unless a waiver was attached to the policy eliminat- 
ing indemnity for disability following this condition. Accident 
insurance could be safely written at almost any time without 
regard to such a history. 

ACUTE GASTRIC CATARRH 

SYNONYMS: Acute indigestion; acute simple gastritis; 
sub-acute gastritis; gastric fever; bilious fever. 

INFORMATION : Acute gastric catarrh is an acute catarrhal 
inflammation of the mucous membrane of the stomach and re- 
sults from errors in diet, such as the taking of indigestible food 
or an excessive amount, poor mastication and edibles which are 
partially decomposed. The abuse of alcoholic liquors is perhaps 
the most common cause of this condition. 

SIGNS AND SYMPTOMS begin with coated tongue, bad 
taste in the mouth, foul breath, loss of appetite, headache, mod- 



440 DISEASES OF THE DIGESTIVE SYSTEM 

erate fever, nausea and sometimes vomiting. In addition there 
is pain and tenderness of the abdomen with distention and in a 
number of cases at the termination of the attack, herpes appear 
about the mouth. Vertigo, with pain in the back of the neck is 
sometimes a distressing symptom. 

DIFFERENTIAL DIAGNOSIS: Typlwid and Remittent 
Fevers may commence with symptoms referable to the stomach 
and a diagnosis of acute gastritis is made, but on account of the 
condition not getting better within a short time the proper diag- 
nosis is soon ascertained. 

Cerebral Disease may be thought to exist on account of the 
prominence of vertigo with pain in the back of the neck, but this 
symptom disappears on the institution of treatment for gastritis. 

HOUSE CONFINEMENT in shght cases of gastric ca- 
tarrh seldom exists, but if the attack is severe from i to 2 or 3 
weeks may be required; if this condition follows a debauch, house 
confinement of from 3 to 7 or 10 days is sometimes necessary. 

TOTAL DISABILITY does not often exist in acute, sim- 
ple cases of gastric catarrh; in the majority of cases the occupa- 
tion is followed while the condition exists. When this inflamma- 
tion follows excessive drinking, total disabihty of from i to 2 or 
3 weeks is sometimes required, but as an insurance poHcy does 
not pay indemnity for disability arising from over-indulgence of 
alcoholic liquors, it is important that the cause of acute gastritis 
and especially in cases that cause total disability, should be 
closely investigated and if found to result from excessive use of 
intoxicating liquors, such ^ claim would be rejected. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, may last from 3 to 7 daA^s in cases which have caused house 
confinement of seven to ten days; this time being necessary on 
account of the weakness that exists. 

EFFECTS: When a history of repeated attacks of acute 
gastritis is secured, it is important to know if this condition is 
the beginning of tuberculosis of the lungs or exists in an indi- 
vidual who uses liquor to excess. In either case a life or health 
policy would not be granted. If it is found by a medical exami- 
nation that the condition is due to neither of these causes, a life 
policy could be safely issued as soon as recovery is complete, but 
a health policy would not be granted without a Avaiver eliminat- 
ing indemnity for disability from this disease. An accident pol- 



ACUTE TOXIC GASTRITIS 441 

icy can generally be sold to a person with such a history without 
reference to the disease, provided the moral hazard is not too 
great. 

ACUTE TOXIC GASTRITIS 

SYNONYM : Toxic gastritis. 

INFORMATION: Acute toxic gastritis is an acute and 
violent inflammation of the membrane lining the stomach and is 
caused by the swallowing of poisons which irritate and corrode 
the internal surface of that organ. Poisons such as corrosive 
sublimate, carbolic acid, solutions of copper or arsenic and strong 
alkalies are the most frequent causes of this condition. 

SIGNS AND SYMPTOMS are manifested at once or 
shortly after the swallowing of a corrosive poison and begin with 
intense, burning pain in the throat and stomach followed by nau- 
sea and persistent vomiting, the ejected matter first being the 
contents of the stomach and this is soon followed by clotted 
blood and shreds of mucous membrane, pain in the abdomen, 
marked thirst, and excessive purging usually exists in such cases. 
Shock is a prominent symptom and is followed by collapse and 
in many cases death, or a slow convalescence when symptoms 
referable to the kidneys and bowels complicate the condition. 

DIFFERENTIAL DIAGNOSIS is extremely important 
when disability or death results from the taking of a corrosive 
poison. If the poison is taken accidentally and evidence to sup- 
port this claim exists, an accident insurance policy would prob- 
ably cover the disability or death which might result, while if a 
disability policy w^as carried, indemnity would not be payable if 
the poison was taken by intent. The character of the poison 
taken either accidentally or by intent is usually diagnosed by the 
stain or effects on the lips or in the mouth. Corrosive sublimate 
leaves a white glazed surface, carbolic acid a white corrugated 
appearance, nitric acid a yellow eschar, sulphuric acid a black or 
gray eschar, chromic acid a yellowish-white stain which in time 
becomes a grayish-brown eschar, while caustic potash causes a 
softening of the tissues with which it comes in contact. 

COMPLICATIONS: Acute Inflammaiion of flic Kidneys fol- 
lows in almost every case of poisoning under the above condi- 
tions, provided the individual lives long enough for this to de- 
velop. When convalescence and recovery take place after the in- 



442 DISEASES OF THE DIGESTIVE SYSTEM 

gestion of a corrosive irritant poisoning and inflammation of the 
kidneys follows, house confinement and disability are greatly pro- 
longed, not only by this condition, but also by the destruction of 
the mucous membrane of the esophagus, stomach and intestines 
which has come in contact with the poison. 

Stenosis resulting from destruction of the tissues and result- 
ing scars, always follows cases in which recovery takes place after 
the ingestion of an irritant poison, but in such cases this condi- 
tion does not occur until some weeks have elapsed and generally 
does not cause disability which is covered by an accident or 
health poHcy. 

HOUSE CONFINEMENT in cases of poisoning seldom 
lasts more than from 12 to 36 hours when a fatal teraiination oc- 
curs. If death does not follow the taking of such a poison and a 
slow convalescence is established, house confinement of from 2 
to 3 or 4 weeks may be necessary. 

TOTAL DISABILITY is not payable under an accident 
policy unless it is clearly proven that the poison was taken acci- 
dentally, when of course an insurance company would only be 
liable for indemnity according to the terms of the policy. If the 
poison was taken by intent, no company would pay disability or 
a death benefit in such a case unless the policy expressly pro- 
vided a specific amount for such a contingency. Total disability 
is seldom long enough to constitute a claim under^ an accident 
policy when a poison has been swallowed accidentally, but if con- 
valescence is established and- the individual has a proper claim 
under the policy, total disability in such cases may last from 2 to 
4 or 6 weeks and even longer. 

PARTIAL DISABILITY is sometimes payable under an 
accident policy when disability results from the swallowing of a 
corrosive poison which has been taken by mistake and death has 
not ensued. In such cases, partial disability invariably follows a 
period of total and may last an uncertain and indefinite time on 
account of the destruction of the mucous membrane over which 
the poison has passed or degeneration of special organs, such as 
the kidneys, liver, etc. 

EFFECTS : When an individual has taken a corrosive 
poison by mistake and has recovered, insurance of all kinds would 
be denied until at least one year or more after complete recovery 
had ensued and no complications resulted. If such a poison had 



GASTRIC ULCER 443 

been taken by intent, all forms of insurance would be withheld 
from such a person. 

GASTRIC ULCER 

SYNONYMS: Peptic ulcer; perforating ulcer; chronic gas- 
tric ulcer; round ulcer of the stomach. 

INFORMATION: A gastric ulcer is situated inside the 
stomach and is generally found on the posterior wall. It is a cir- 
cumscribed ulceration with loss of tissue and is supposed to be 
due to the action of the hydrochloric acid in the gastric juice 
upon the mucous membrane which has been unpaired from some 




Fig-. 10 5. — Gastric ulcer, showing erosion into a blood-vessel in 
the floor of the ulcer. (Bollinger). 

cause or other. It is more common in women than in men and 
is usually a chronic condition and disability seldom results unless 
a perforation occurs or an operation is performed for the cure 
of this condition. 

SIGNS AND SYMPTOMS: Ulcer of the stomach causes 
indigestion, with pain in the abdomen which is aggravated by the 
ingestion of food. Vomiting of the stomach contents and also 
blood which in most cases is expelled before it is acted upon by 
the gastric juice, is a common sign. Sometimes, however, it is 
retained long enough to become altered by the gastric juices and 
then it has a cofifee-ground appearance. There is tenderness over 
the stomach and hyperacidity is almost invariably present. Fre- 
quent attacks of gastralgia occur when an ulcer is present. 



■sif^^^«n 



444 DISEASES OF THE DIGESTIVE SYSTEM 

DIFFERENTIAL DIAGNOSIS : Cancer of the Stomach is 
usually seen in persons past forty years of age; its course is 
rapid, severe pain is present with loss of weight and color, vomit- 
ing of blood which has been disintegrated and has the character- 
istic cofTee-ground appearance occurs at irregular intervals and 
hydrochloric acid is absent, while lactic acid is present in large 
quantities. 

Cholelithiasis is characterized by pain in the right hypochon- 
drium occurring suddenly and radiating towards the right 
shoulder and is not associated with the taking of food; tenderness 
and rigidity over the gall-bladder are present and moderate fever, 
with jaundice sometimes occurs. 

Chronic Gastritis is not uncommonly diagnosed when a gas- 
•tric ulcer exists, but in this disease there is a history of over-in- 
dulgence in alcoholic liquors or excessive over-eating and per- 
sistent indigestion covering a number of months or years with 
slight pain in the epigastrium which is not aggravated by the tak- 
ing of food and vomiting is unaccompanied by blood. 

Gastralgia is marked by paroxysms of intense pain which oc- 
cur at irregular intervals and are not connected with the inges- 
tion of food. Absence of vomiting and amelioration of the pain 
by pressure is noticed and in some instances when food is swal- 
lowed. Hematemesis or hyperacidity is not present in gastralgia. 

COMPLICATIONS : Perforation of the Stomach is the most 
common complication and when this occurs the signs and symp- 
toms of shock are soon followed in the majority of cases by evi- 
dence of peritonitis. In such cases disability results at once and 
persists until death terminates the case or an operation is per- 
formed for the cure of the condition. 

Hemorrhage often accompanies a perforation and when ex- 
cessive may cause a fatal termination unless an immediate oper- 
ation is performed. 

HOUSE CONFINEMENT seldom occurs in cases of ulcer 
of the stomach unless some of the complications ensue or a vol- 
untary operation is performed for the cure of this condition. If 
a perforation or hemorrhage takes place death may result within 
from 3 to lo days; during which time house confinement exists. 
When an operation is necessary on account of a complication, 
house confinement lasts from 2 to 4 or 6 weeks and sometimes 
longer on account of the debilitated condition of the individual 



INTESTINAL OBSTRUCTION 445 

before an operation is rendered obligatory by a perforation or 
large hemorrhage. 

TOTAL DISxA^BILITY is rarely payable in cases of ulcer of 
the stomach unless a compHcation ensues or an operation is vol- 
untarily undergone. If a perforation with peritonitis occurs and 
death follows within a short time, total disability does not often 
last more than i to 2 weeks. If this complication arises and an 
operation is performed it is usually done at once, when total dis- 
ability lasts from 4 to 6 weeks and sometimes longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is sometimes required when an operation has been ren- 
dered necessary b}^ a complication arising in connection with this 
disease and in such cases from 2 to 4 or 6 weeks may be de- 
manded on account of the poor physical condition of the indi- 
vidual after the operation. 

EFFECTS : When a gastric ulcer is suspected as existing in 
an individual, such a person is not insurable for life or health in- 
surance, although accident insurance can generally be written 
without any increased hazard. If a gastric ulcer has been volun- 
tarily removed by an operation or on account of perforation and 
recovery ensues and is complete, life or health insurance can be 
written from four to eight months after complete recovery, if 
during this time all evidence of indigestion and the signs and 
symptoms of the former condition have disappeared. 

INTESTINAL OBSTRUCTION 

SYNONYMS: Intestinal stricture; intestinal occlusion; 
strangulated hernia; obstruction of the bowels; invagination; 
ileus. 

INFORMATION: Intestinal obstruction results from 
causes which produce a sudden or gradual closing of the intes- 
tinal canal. It may result from strictures in the bowel itself. 
strangulations which are caused by strictures within the abdom- 
inal cavity, invagination, twisting of the intestines, pressure by 
growth within the abdomen and accumulations of hardened feces 
or foreign bodies in the intestines, paresis and congenital malfor- 
mation. 

SIGNS AND SYMPTOMS are sudden or gradual in onset 
according to the cause of the obstruction. AVhen it is acute, ab- 



446 DISEASES OF THE DIGESTIVE SYSTEM 

dominal pain comes on suddenly and at first in paroxysms, but 
later the pain is continuous. Constipation is present, vomiting 
begins, first the contents of the stomach and later regurgitation 
of the intestinal matter into the stomach occurs and is ejected 
by the mouth, attended with signs and symptoms of collapse. If 
the obstruction is of long duration and gradually closes the lumen 
of the bowel, the symptoms are slow in onset, consisting of con- 
stipation which becomes more marked as the stricture contracts, 
pains in the abdomen with distention and impaired health. If the 
obstruction is due to a stricture of the bowels, the discharges are 
ribbon-shaped and sometimes associated with blood and mucus. 

DIFFERENTIAL DIAGNOSIS: Appendicitis may be 
diagnosed as intestinal obstruction, but in the former there is a 
fixed area of tenderness over McBurney's point with swelling; 
vomiting is never fecal in character and usually subsides within 
twenty-four hours, while the passage of gas per rectum and 
movement of the bowels is always possible. 

Peritonitis is sudden in onset following a chill, with elevated 
temperature, distention of the abdomen and rigidity of the ab- 
dominal walls, the characteristic position is assumed on the back 
with the limbs drawn up and nausea and vomiting follow, the lat- 
ter, however, is not of a stercoraceous character. 

Catarrhal Enteritis in the earl}^ stages may be mistaken for 
obstruction of the bowels. In this condition, however, the diar- 
rhea which is present becomes more marked as the disease pro- 
gresses, absolutely eliminating any obstruction. 

Hepatic Colic sometimes resembles obstruction of the bow^- 
els, but when pain is caused by the passage of one or more gall- 
stones, it is agonizing and is located in 'he re.eion of the gall- 
bladder and radiates over the chest and shoulder. Nausea and 
vomiting occur, but of the latter, the contents of the stomach 
only are expelled. Jaundice is present and movement of the boAV- 
els takes place. 

Renal Colic is best diagnosed by the situation of the pain in 
the back which is referred in the male to the corresponding tes- 
ticle. It terminates suddenly as the stone passes into the bladder 
and is accompanied by hematuria, albuminuria and movement of 
the bowels. 

Acute Hemorrhagic Pancreatitis is sometimes mistaken for in- 
testinal obstruction. This condition, however, produces pallor 
of the face, prostration, collapse and evidence of a tumor in the 



INTESTINAL OBSTRUCTION 447 

left upper part of the abdomen, while the passage of gas or move- 
ment of the bowels occurs naturally. 

COMPLICATIONS: Peritonitis may result from a strangu- 
lation of the bowel which becomes ruptured or gangrenous from 
the constriction. In such cases, death is almost invariable unless 
an immediate operation is performed for the cure of this condi- 
tion, when disability is prolonged as the result of the operation. 

HOUSE CONFINEMENT in all classes of risks lasts from 
I to 2 Wrecks when recovery follows without an operation. If 
death occurs, it generally takes place within ten days from the 
beginning of absolute obstruction. If an operation is performed 
to relieve the obstruction, house confinement lasts from 2 to 4 
weeks after the date of operation and this is usually preceded by 
about I week of confinement to the house and bed. 

TOTAL DISABILITY in cases of acute intestinal obstruc- 
tion lasts from i to 2 weeks, when relief follows as the result of 
medical treatment or if death occurs, total disability is usually the 
same length of time; namely, i to 2 weeks. When an operation 
is performed, total disability lasts from 4 to 6 weeks from the date 
of the beginning of disability. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, generally requires from i to 2 weeks, this time being 
necessary before the occupation can be resumed. 

EFFECTS : When a history of obstruction of the bowels 
exists in any case, it is necessary that the exact cause be known 
before an opinion as to the insurability of the risk can be given. 
If the obstruction has been due to a stricture in the wall of the 
bowel and this part h s been removed and no evidence of any 
further trouble of the same kind is discovered at the time of the 
operation, life or health insurance can be issued from two to three 
years after recovery is complete. Should the obstruction have 
been due to a strangulation which was caused by adhesions within 
the abdominal cavity, it is questionable if a life policy could be 
issued on such a risk, but a health policy could be written with a 
waiver eliminating indemnity for disability from this condition. 
Invagination or intussusception is most common in children and 
if relieved by an operation when it occurs in an adult, such a his- 
tory would have little bearing on the insurability for life or health 
insurance, if two to three years have elapsed after the operation. 
The same also applies to a twisting or rotation of the bowol. If 



^ 



448 DISEASES OF THE DIGESTIVE SYSTEM. 

the operation resulted from accumulations within the intestines 
due to irregular living or obstinate constipation, other conditions 
would have to be considered before a life policy could be writ- 
ten, but a health policy could be issued with a waiver eliminating 
disability when caused by obstruction of the bowels. If pressure 
by a tumor or foreign growth within the abdominal cavity causes 
this condition, the fact that intestinal obstruction occurred would 
have no bearing on the insurability of the risk; it being necessary 
to consider the cause of the obstruction in the granting of a life 
or health poHcy. Accident insurance can generally be safel}^ 
written on individuals with a history of obstruction of the bowels 
from three to six months after complete recovery, provided the 
other history is unobjectionable. 



PROCTITIS 



SYNONYMS: Rectitis; catarrh of the rectum. 

INFORMATION: Proctitis is an inflammation of the mu- 
cous membrane of the rectum and anus and is most commonly 
caused by constipation, exposure resulting from the sitting on 
damp ground or stone steps, constant use of enemata or purga- 
tives, hemorrhoids and -diseases of the liver. When a proctitis 
is alleged as the cause of disability, it is important to know if a 
fistula developed, as in the majority of cases this condition is tu- 
berculous in origin and if this disease exists, it has been present 
for some time and the individual is not insurable for any kind of 
a polic3^ 

SIGNS AND SYMPTOMS: Proctitis usually begins with 
headache, moderate fever and general malaise accompanied by a 
burning pain in the rectum and a constant desire to evacuate the 
bowels. The stools are either hardened feces which cause intense 
pain as they are discharged or mucus in character with blood or 
blood and pus. When a movement occurs, there is often a pro- 
lapse of the lower part of the rectum. 

DIFFERENTIAL DIAGNOSIS: Proctitis may be seen in 
conjunction with a carcinoma of the rectum; in which case there 
is severe pain, emaciation, loss of color and strength. 

COMPLICATIONS: Abscesses of the Liver are sometimes 
complicated with proctitis; when the disability is governed by 
the more serious disease. 

Periproctitis or inflammation around the anus results from 



4 



PROCTITIS 



449 



the above conditions and is often complicated with fistulse of var- 
ious kinds. When these occur, disability is greatly prolonged by 
the complication even after the original disease is cured. 

Localized Peritonitis may result from the inflammation in- 
volving the rectum, when disability usually results. If the peri- 
tonitis is due to a perforation in the wall of the rectum and an ab- 
scess follows and discharges through this canal, disability is 
greatly prolonged. 

HOUSE CONFINEMENT in uncomplicated cases of proc. 




FIG. 106. — COMPLETE PROLAPSE OF THE RECTUM. 
L, Depression corresponding to lumen of rectum; PM, prolapsed 
of rectum. 



(Eisendrath). 
mucous membrane 



titis does not often follow, for the reason that it exists at irregular 
intervals and lasts a day or part of a day only. When this in- 
flammation is complicated by a more serious disease house con- 
finement may be present, but in such cases it is controlled by the 
complication rather than the proctitis. 

TOTAL DISABILITY in uncomplicated cases of this in- 
flammation depends on the course and severity. Usually, how- 
ever, the disability is not continuous and therefore it is not cov- 



T-T 



450 DISEASES OF THE DIGESTIVE SYSTEM 

ered by a health or disability policy. If the inflammation be- 
comes so severe as to cause house confinement, total disability 
of I to 2 weeks may result. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, when necessary after a severe attack of this inflammation 
in which house confinement of a week or more has been present, 
may require from i to 2 or 3 weeks of this form of disability. 

EFFECTS : Individuals having suffered from an uncompli- 
cated attack of proctitis are insurable for all forms of insurance 
from two to four months after the condition has been cured.' If 
the inflammation was due to or complicated by an organic dis- 
ease of the rectum or surrounding tissue, all forms of insurance 
would be denied such a person. When a proctitis results in a 
fistula, life, accident or health insurance cannot be issued until at 
least six months after the cure of this complication and not until 
a medical examination has been made and the individual shown 
to have fully recovered. 



CHAPTER XVII 

DISEASES OF THE LIVER 

ABSCESS OF THE LIVER 

SYNONYMS: Acute hepatitis; parenchymatous hepatitis; 
suppurative hepatitis. 

INFORMATION: Abscess of the Hver may be single or 
muhiple and when found to be present are usually situated in the 
right lobe. They are caused by micro-organisms which accom- 
pany diseases of the intestines and result from septic emboli that 
are carried to the liver tissue from a suppurating focus in another 
part of the body. Traumatism is rarely the cause of an abscess 
in this location. 

SIGNS AND SYMPTOMS are usually obscure and the 
diagnosis of this condition is extremely difificult. When an ab- 
scess of the liver exists, that organ is enlarged, tender and pain- 
ful, and if the pus is encapsulated near its surface, the skin in this 
situation shows redness and edema and in some cases fluctuation 
can be detected. The enlargement may also cause bulging be- 
neath the costal arch. Intermittent or remittent fever with 
chills, sweating, jaundice and symptoms referable to the nervous 
system are present when this condition exists An abscess of the 
liver may evacuate itself into the chest or abdominal cavity, 
stomach or intestines, producing characteristic symptoms. 

DIFFERENTIAL DIAGNOSIS: Impacted Gall-sfones may 
be existing and show a history of long standing. This condition 
is characterized by pain accompanied by fever of an intermittent 
or remittent type and occurring at irregular intervals. Jaundice 
is present and becomes more marked as the paroxysms increase 
in number and the longer the impaction is present. 

Cancer of the Liver is diagnosed by the history, age, evidence 
of a nodular sweUing, loss of weight and color, jaundice, weak- 
ness and in some cases involvement of other organs. 

Hydatid Cysts usually occur in isolated quarters and this con- 
dition is rare in America. When it does exist, a large number of 
cysts are formed, irregular enlargement of the liver follows, fluc- 

451 



^mm 



452 



DISEASES OF THE LIVER 



tuation is detectable and on aspiration a fluid containing the 
characteristic booklets is obtained. 

COMPLICATIONS: Pleurisy and Pneumonia may follow 
an abscess of the liver which ruptures into the pleural cavity. In 
such cases, disabihty is very uncertain and greatly prolonged. 

Peritonitis either general or locaHzed may follow the rupture 
of an abscess of the liver into the peritoneum, stomach or intes- 
tines. 

HOUSE CONFINEMENT is extremely uncertain and de- 
pends on the location of the pus, the amount of tissue involved, 



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Fig-. 107. — Intermittent fever in abscess of the liver. (Musser). 

whether the abscess is allowed to rupture spontaneously or is 
evacuated by an operation. If a single small abscess exists and 
the pus is evacuated by nature or an operation is performed at an 
early date, house confinement of from 2 to 3 weeks only may be 
necessary. If a larger abscess is formed it may require confine- 
ment to the house and bed from 4 to 6 or 8 weeks, this time 
being governed by the above enumerated conditions. When an 
operation is performed, house confinement is prolonged from the 
date of operation from 3 to 6 weeks. 

TOTAL DISABILITY is also uncertain when an abscess of 



CHOKELITHIASIS 453 

the liver exists and lasts from 4 to 10 or 16 weeks. The longer 
time often being necessary for abscesses of this organ occurring 
in the tropics. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment may require from 4 to 8 or 12 weeks and sometimes longer; 
this depending on a number of conditions which govern the 
length of disability and the resulting physical condition. 

EFFECTS: Individuals who have spent more or less time 
in the tropics and suffered from an abscess of the liver are not 
insurable for a Hfe or health policy unless five to ten years or 
more have elapsed without any symptoms referable to this trou- 
ble. When a small abscess existed and was evacuated early, such 
a person can sometimes be insured for a life or health policy 
from one to two or three years after the termination of this con- 
dition. Accident insurance can be issued from six to twelve 
months after complete recovery follows from an abscess of the 
liver. 

CHOLELITHIASIS 

SYNONYMS: Gall-stones; biliary calculi; hepatic calculi; 
hepatic coHc. 

INFORMATION : Biliary calculi are much more common 
in females than in males and occur more frequently after forty 
years of age. They vary in size and shape, from that of a small 
grain of sand to that of a large walnut and may be found in any 
number from one to several hundred; usually being light yellow 
or dark green in color and composed chiefly of cholesterin with 
some bile-pigments and liver-salts. Gall-stones are said to result 
from a number of causes, the most probable being the action of 
a micro-organism on the gall-bladder, which causes an over-secre- 
tion and the formation of stones. They are also seen in those 
whose habits of life are sedentary. 

SIGNS AND SYMPTOMS : An attack of biliary colic be- 
gins suddenly and is caused by the passage of one or more gall- 
stones from the gall-bladder into the cystic duct where impaction 
occurs but sometimes this condition takes place in the lower part 
of the common duct. During the passage of a stone or stones 
intense pain exists over the region of the liver and radiates into 
the rieht chest and shoulder of the same side. Tenderness is 



^fiivmw 



454 



DISEASES OF THE LIVER 



complained of when pressure is made over the gall-bladder, mod- 
erate fever exists with nausea and vomiting, feeble pulse, cold 
perspiration and an anxious expression of the face. Jaundice 
more or less marked may follow an attack of bihary colic, but is 
not always constant. As soon as the calculus reaches the intes- 
tines, all signs and symptoms of the pain cease and the stone is 
later found in the stools. Attacks of biliary colic last from a few 





Fig. 108. — Gallstone in cystic 
duct. (Musser). 



Fig. 109.— Gallstone in hepatic 
duct. (Musser). 




Fig. 110. — Gallstone' in com- 
mon duct, (Musser). 



rhinutes to several hours and sometimes even extend over several 
days. 

DIFFERENTIAL DIAGNOSIS: Gastralgia is diagnosed 
by the history of repeated attacks, with absence of jaundice or the 
finding of gall-stones in the stools. The pain is in the region of 
the stomach and is relieved by pressure or the swallowing of food 
and occurs more often in individuals of a neurotic temperament. 

Ulcer of the Stomach shows a history of long standing with 
pain in that organ which radiates to the back and is increased by 



CHOLELITHIASIS 455 

eating; vomiting of blood is frequent and hyperacidity of the gas- 
tric contents is constantly present. 

Intestinal Colic results from the ingestion of indigestible food, 
over-eating or over-indulgence in alcoholic liquors and is char- 
acterized by colicky pains around the umbilicus, together with 
distention of the abdomen by gas and borborygmi. 

Renal Colic is marked by pain in the region of the kidneys 
which radiates along the ureter and into the loins. Jaundice is 
absent, but pus and blood, together with albumin are found in 
the urine which is passed frequently. 

COMPLICATIONS: Localized Peritonitis almost invariably 
complicates an attack of biliary colic and this is especially true if 
the condition remains for any length of time. This complica- 
tion, however, is usually so slight that it seldom causes any dis- 
ability or prolongation of that resulting from the primary inflam- 
mation. 

HOUSE CONFINEMENT seldom lasts more than i to 2 
days when a single stone is passed. If a number are expelled, at- 
tacks of biliary colic may occur at irregular intervals but close 
together, when house confinement of i to 2 weeks may result. 
Usually, however, house confinement is not long enough to be 
covered by a health policy except when indemnity is paid for less 
than seven days. 

TOTAL DISABILITY under the majority of health poli- 
cies does not follow when gall-stones are passed, unless a number 
of attacks succeed the first one, when total disability of from i 
to 2 or 3 weeks may be required. The latter part of this time 
being necessary on account of the weakened condition of the in- 
dividual which follows from the repeated attacks of severe pain. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is not often demanded and when required, from i to 2 
weeks are generally suf^cient. 

EFFECTS: When a history of biliary colic exists, health 
insurance would not be granted unless a waiver was placed on 
the policy eliminating indemnity for disability due to this condi- 
tion, and in such cases, a health policy would not be issued until 
at least six months had elapsed after the last attack. The issu- 
ance of a life polic}^ would depend on a number of conditions and 
would not be issued until six to twelve months had passed after 
the last attack and the niedical examination had shown all other 



456 DISEASES OF THE LIVER 

conditions favorable. Accident insurance could be safely granted 
from three to six months after the termination of an attack, pro- 
vided the risk be normal in all other respects. 

CARCINOMA OF THE LIVER 

SYNONYMS: Cancer of the liver; hepatic cancer. 

INFORMATION: Carcinoma of the liver occurring as a 
primary cancer is rarely seen; the more usual form being known 
as the secondary cancer and this follows when such a morbid 
growth exists in other parts of the body. It is more common in 
men than in women and usually occurs after forty years of age 
and is said to be hereditary, due to irritations from gall-stones 
and in rare instances from traumatism. 

SIGNS AND SYMPTOMS : Cancer of the liver develops 
slowly and is preceded by a history of chronic indigestion and 
constipation. The liver becomes enlarged and painful and small 
nodules develop on the surface. Jaundice is present and cachexia 
soon appears. 

DIFFERENTIAL DIAGNOSIS: Syphilitic Enlargement of 
the liver is preceded with a history of infection in which the prom- 
inent signs of this disease show themselves. It may occur at any 
stage and does not produce cachexia, such as results when cancer 
exists. Localized pain is complained of and a moderate elevation 
of temperature exists. 

Abscess of the liver is diagnosed from cancer by the history, 
together with the hectic temperature which exists in all such 
cases and an exploratory incision or puncture serves to make the 
diagnosis clear. 

Cirrhosis of the liver in one of the various forms may be mis- 
taken for a cancer of this organ, but in cirrhosis a history that 
would produce this condition usually exists. It occurs at all ages 
and when present, the characteristic cachexia seen in cancer of 
the liver does not occur. 

COMPLICATIONS : Cancer of the liver usually exists as a 
complication and follows the involvement of some other organ 
or part of the body. In such cases it is a secondary infection and 
usually prolongs a pre-existing disabihty. 

HOUSE CONFINEMENT does not often occur in this dis- 
ease until near the termination of the life, and when it once be- 
gins it almost invariably persists until death ends the case. In 



CIRRHOSIS OP THE LIVER 457 

such cases it is uncertain and may last from i to 3 weeks only, 
again from 2 to 3 months or more. 

TOTAL DISABILITY: Cancer of the liver almost always 
causes a fatal termination within one year from the time it is 
diagnosed, but total disabihty does not usually begin until near 
the end of the life of the individual, when it may last from i to 2 
months only or by beginning early in the disease persist as long 
as 6 to 8 months. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the end of house confinement, is 
never required in such cases, for the reason that when house con- 
finement once begins it is constant until the case terminates by 
death. 

EFFECTS: Individuals with a history of an obscure trou- 
ble of the liver which may or may not be a cancer of this organ 
are not insurable for any kind of a policy while an uncertain diag- 
nosis exists. If it is shown after three to five years that a cancer 
has not been present and all other things are equal, life or health 
insurance may be considered, but the issuance of a life, health or 
accident policy would depend upon the results of a medical ex- 
amination. 

CIRRHOSIS OF THE LIVER 

SYNONYMS: Sclerosis of the liver; interstitial hepatitis; 
hardening of the liver; gin-drinkers' liver; hob-nailed liver. 

INFORMATION: Cirrhosis of the liver is a slow, chronic 
inflammatory process, characterized by a hyperplasia of the con- 
nective tissue which results in hardening and contraction and a 
destruction of the liver-cells which secrete the bile. It is more 
common in males than in females, usually occurs during middle 
life and most frequently results from the continued and prolonged 
use of alcoholic liquors. It is also caused, by chronic diseases 
such as syphilis, tuberculosis, malaria and chronic diseases of the 
heart and kidneys. 

SIGNS AND SYMPTOMS are divided by most writers 
into two stages; the first stage generally persists for months or 
years and during this time there is coated tongue, loss of appe- 
tite, dyspepsia with flatulency, nausea, vomiting and constipation. 
When these symptoms are complained of by an individual who is 
constantlv drinking to excess, a beginnino- hardonino- of tb.e liver 



TTT- 



458 DISEASES OF THE LIVER 

would be suspected. The symptoms of the second stage are a 
continuation of those seen in the early stage and consist of 
chronic dyspepsia, with enlargement of the spleen and superficial 
veins of the abdomen together with dropsy, some pain over the 
region of the liver, slight jaundice, hemorrhoids and loss of flesh 
and strength. 

DIFFERENTIAL DIAGNOSIS: Chroiiic Peritonitis which 
has existed for some time and is accompanied by an effusion may 
resemble cirrhosis of the liver. When peritonitis of this form ex- 
ists, it is usually due to tubercles scattered throughout the peri- 
toneum and the diagnosis is made by the ascites which develops 
rapidly, the absence of jaundice, changes in the size of the liver 
and by an exploratory incision which makes the diagnosis clear. 

COMPLICATIONS : Cirrhosis of the liver is almost invari- 
ably complicated by diseases of the heart, blood vessels and kid- 
neys. Tuberculosis of the peritoneum is also a common compli- 
cation and almost any other chronic disease may be suspected. 

HOUSE CONFINEMENT rarely occurs in those suffer- 
ing from cirrhosis of the liver until that organ has become so 
badly diseased that its functional activity is almost ended. In 
such cases, house confinement marks the termination of the ill- 
ness and is continuous or it exists from i to 2 or 3 days at a time, 
when the individual is sufficiently recovered by rest and diet to 
be able to leave the house for a few days when house confinement 
again occurs. When it is present as a continued period, it may 
be as short as from 2 to 7 days only; other times from 2 to 6 or 8 
weeks may be necessary before death occurs. 

TOTAL DISABILITY does not ensue until near the ter- 
mination of the disease. This period may be short, sometimes 
lasting only from 2 to 7 or 10 days, at other times when house 
confinement is not continuous, total disability may last from i 
to 2 or 3 months. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the pohcy after the termination of house confine- 
ment is not necessary in these cases as recovery never occurs. 

EFFECTS : If the diagnosis of cirrhosis of the liver is 
made in an individual, that person is not insurable for any kin-d of 
insurance, and if a policy is carried by such a person and is of re- 
cent issue, it is almost proof positive that it was secured by mis- 
representations. 



CONGESTION OF THE LIVER 459 

CONGESTION OF THE LIVER 

SYNONYiMS: Biliousness; torpid liver; hyperemia of the 
liver. 

INFORMATION : Congestion of the liver may be active 
or passive; the active form causing short periods of disability. It 
is due to over-indulgence in eating and drinking of alcoholic 
liquors, exposure to high atmospherical or artificial heat, habitual 
constipation and malaria. 

SIGNS AND SYMPTOMS : Active hyperemia of the liver 
generally begins rapidly with headache, feverishness, flatulency, 
nausea, anorexia, constipation and a feeling of weight and sore- 
ness over the right hypochondriac region; slight jaundice may 
also appear. Passive hyperemia is gradual in onset with practi- 
cally the same symptoms, consisting of pain in the hepatic region, 
jaundice and chronic indigestion. Percussion shows an increased 
area of dullness. 

DIFFERENTIAL DIAGNOSIS: Catarrhal Jaundice is 
usually mistaken for active congestion of the liver, but in this dis- 
ease the history, together with pronounced gastro-intestinal 
symptoms and jaundice serve to make the diagnosis. 

Obstructive Jaundice in the early stages is sometimes diag- 
nosed for acute hyperemia of the liver, but in this condition jaun- 
dice is slight at first and gradually becomes more marked until 
the skin is stained a deep yellow. Mental depression exists with 
a slow pulse and slightly subnormal temperature and later itch- 
ing- of the skin follows, and in severe cases delirium and coma 
sometimes occur. 

HOUSE CONFINEMENT rarely lasts more than from 3 
to 7 days when the inflammation subsides in acute hyperemia of 
the liver and the occupation can be resumed. Passive hyperemia 
seldom causes house confinement, except when it is a complica- 
tion of some other disease. 

TOTAL DISABILITY in cases of acute congestion of the 
liver usually lasts from 5 to to days, when all classes of risks' are 
able to resume the usual duties of the occupation. Passive con- 
gestion unless compHcated by some other disease almost never 
causes total disability. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable after the termination of house confinement is rarely 
necessary. 



iUI .. T fft^KrmSBIF 



460 - DISEASES OF THE LIVER 

EFFECTS : Individuals having suffered from an attack of 
active congestion of the Hver are insurable for any kind of a 
policy from three to six months after complete recovery. When 
passive congestion has existed and is due to some intercurrent 
disease, insurance of all kinds must be denied a person suffering 
with such a condition. 

CATARRHAL JAUNDICE 

SYNONYMS: Icterus; jaundice; catarrhal angiocholitis; 
catarrhal hepatitis; catarrh of the bile-ducts. 

INFORMATION : Catarrhal jaundice is an acute inflamma- 
tion of the mucous membrane lining the bile ducts and is caused 
by exposure, over-eating and drinking, irritation by gall-stones, 
some of the infectious fevers, but most commonly it is due to an 
extension of an inflammation of the duodenum. 

SIGNS AND SYAIPTOMS: This disease usually begins by 
loss of appetite with coated tongue, foul breath, pain over the 
stomach, slight fever, nausea, vomiting and diarrhea. These are 
followed in a few days by itching of the skin which has become 
harsh and dry, constipation with clay-colored stools, distention of 
the abdomen by gas and a yellowish discoloration of the conjunc- 
tiva of the eyes, where it first appears and gradually extends over 
the body until the whole skin takes on a yellow-greenish hue. 
The urine is of high specific gravity, dark in color and contains 
the coloring matter of the bile. 

DIFFERENTIAL DIAGNOSIS: Jaundice must be diag- 
nosed from other forms of discoloration which resemble it. 

Addison's Disease is extremely rare and is characterized by a 
bronzing of the skin with a pigmentation of the mucous mem- 
brane and pronounced gastric symptoms. Discoloration of the 
conjunctiva of the eyes and bile in the urine is absent in this dis- 
ease. 

Chlorosis occurs almost exclusively in women between fifteen 
and twenty-five years of age. The greenish discoloration of the 
skin in some resembles jaundice, but is unaccompanied by a stain- 
ing of the conjunctiva or the presence of bile in the urine. 

HOUSE CONFINEMENT in an average case of catarrhal 
jaundice lasts from 2 to 3 weeks, but this time is increased about 
I week when the disease terminates during inclement weather. 
When an especially severe attack has been suffered, house confine- 



CATARRHAL JAUNDICE 461 

ment of from 3 to 4 and even 6 weeks may sometimes be neces- 
sary. 

TOTAL DISABILITY lasts from 2 to 4 weeks in the ma- 
jority of cases, although this period may be increased from i to 3 
weeks when an especially severe inflammation has existed. It is 
not necessary that total disability persists until all evidence of dis- 
coloration in the skin disappears, as this may remain some time 
after all disability is ended. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, usually demands i to 2 weeks in all classes of risks. 

EFFECTS : Individuals with a history of an attack of ca- 
tarrhal jaundice which has subsided without any complications 
and was not due to the passage of stones or any organic disease 
in the region of the gall-bladder, could be insured for life or 
health insurance from three to six months after complete recov- 
ery. If a histor}^ of repeated attacks of this inflammation exists, 
life or health insurance would not be issued on such a person. 
Accident insurance can be safely written from one to two months 
after recovery from the first attack, but it is questionable if an in- 
surance compan}^ would wTite accident insurance on any one who 
had suffered disabilitv a number of times from this condition. 



ffTT" 



T^TSTBTTT 



PLATE XIII 




1. Blood casts^ some composed of disin- 
tegrated red blood-cells. 




2. a. Squamous epithelium from the 
urine, b. Epithelial casts. 




3. Hyaline casts. 




5. Cylindroids. 




Waxy casts 



Various Forms of Urinary Casts. 

(Salinger and Kalteyer.) 



CHAPTER XVIII 

DISEASES OF THE KIDNEYS AND BLADDER 

ACUTE PARENCHYMATOUS NEPHRITIS 

SYNONYMS: Congestion of the kidneys; acute Bright's 
disease; acute tubular nephritis; acute desquamative nephritis; 
acute croupous nephritis. 

INFORMATION: Acute parenchymatous nephritis is an 
acute inflammation of the epithehum of the tubules of the kidneys 
and is more common in the young than in the aged. It is caused 
by exposure to cold and wet and follows some of the acute infec- 
tious diseases. It is also due to the elimination of poisons 
through the kidneys and sometimes is seen in conjunction with 
severe burns which involve a large surface of the skin. It is rarely 
caused by blows and injuries to the back. 

SIGNS AND SYMPTOMS: Severe attacks of this disease 
usually develop suddenly with headache, a dull pain in the back 
over the region of the kidneys, slight fever with nausea and per- 
sistent vomiting. The skin is dry and harsh, pulse quick and 
tense and dyspnea is present. Dropsy begins in the face and 
gradually becomes general and may be followed at any time by 
convulsions and uremic coma. The urine is of high specific grav- 
ity, scanty, of a smoky color and contains blood, epithelium, al- 
bumin, hyaline, and epithelial casts with crystals of various kinds. 

DIFFERENTIAL DIAGNOSIS: An attack of acute 
parenchymatous nephritis must be differentiated from an acute 
exacerbation of a chronic parench3^matous nephritis and this 
diagnosis is made by the history, together with an examination 
of the urine which sHows fatty casts when a chronic parenchyma- 
tous nephritis is existing and is complicated by an acute exacer- 
bation. 

Alhvtmimiria which occurs in conjunction with some of the 
acute diseases such as diphtheria, erysipelas, etc., nuist not be 
mistaken for an acute attack of parenchymatous nephritis. When 
albuminuria occurs alone and an acute parenchymatous inflam- 

463 



^fP^^^ffHP 



464 DISEASES OF THE KIDNEYS AND BLADDER 

mation is not present, it exists as a complication of some acute 
disease or is a chronic condition. 

COMPLICATIONS: Pericarditis is frequently seen as a 
complication of acute nephritis and comes on in an insidious man- 
ner, being diagnosed by the heart symptoms which are produced 
by this disease and described under Pericarditis. The period of 
disability is prolonged when this complication exists. 

Pneumonia and Pleurisy may be seen 'in conjunction with an 
attack of acute parenchymatous nephritis; some cases presenting 
all three diseases at the same time. When an inflammation in- 
volving the lungs or pleura is present, the signs and symptoms 
referable to such diseases present themselves, and the disability is 
increased according to the complication. 

Peritonitis, due to an extension of the inflammation involving 
the kidney may sometimes be seen in an attack of acute nephritis. 
Unless the peritonitis becomes general, the localized inflamma- 
tion usually subsides by the time the acute nephritis is ended and 
disability is not prolonged. 

Uremia is perhaps the most common complication of acute 
nephritis and when it occurs the period of disability is increased. 
For the signs and symptoms of this complication see description 
of Uremia. 

HOUSE CONFINEMENT lasts from i to 2 weeks in mild 
cases of acute parenchymatous nephritis in all classes of indi- 
viduals. If the attack is a severe one, confinement to the bed and 
house of from 3 to 4 or 5 weeks may be necessary and this period 
is sometimes prolonged from 3 to 7 days if the house confinement 
terminates during cold and inclement weather. When acute 
nephritis complicates an attack of some of the acute infectious 
diseases, house confinement is generally prolonged from i to 3 
weeks according to the severity of the complication. 

TOTAL DISABILITY in mild cases which are uncomph- 
cated with any other disease, lasts from 2 to 3 weeks. If the at- 
tack is severe and house confinement is lengthened on account 
of the weather conditions, total disabiHty may last from 4 to 5 or 
6 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if provided by the policy after the termination of house confine- 
ment, does not often require more than i to 2 weeks when the 
individual will have sufficiently recovered to resume part of the 
occupation. 



I 



CHRONIC PARENCHYMATOUS NEPHRITIS 465 

EFFECTS : An attack of acute parenchymatous nephritis 
renders an individual uninsurable for life or health insurance until 
three to six months have elapsed after the termination of the dis- 
ease, and the medical examination shows a complete recovery 
with a normal condition of the urine. Chronic parenchymatous 
nephritis or chronic interstitial nephritis does not often follow 
an acute attack of this form of inflammation of the kidneys, but 
insurance companies are generally very careful about accepting 
applicants for life or health insurance until it is positively known 
that a complete and permanent recovery has been effected. If 
the inflammation has been due to the taking of poisonous sub- 
stances by intent, such a person would thereafter be uninsurable 
for all kinds of insurance. Accident insurance can be safely writ- 
ten from one to two months after recovery is said to be complete. 

CHRONIC PARENCHYMATOUS NEPHRITIS 

SYNONYMS: Chronic Bright's disease; chronic nephritis; 
chronic tubular nephritis; chronic croupous nephritis; chronic ca- 
tarrhal nephritis; chronic albuminuria; large white kidney. 

INFORMATION : Chronic parenchymatous nephritis is a 
chronic inflammation of the secreting portion of the kidneys and 
is more common in the male adult between twenty-five and fort}" 
years of age. It is caused by habitual exposure, alcoholism, 
syphilis, chronic diseases, poisoning from mineral substances, pro- 
tracted suppuration and in rare instances, the acute form be- 
comes chronic. 

SIGNS AND SYMPTOMS develop so gradually that the 
disease is not recognized until dropsy appears under the eyes and 
gradually extends over the body. It is accompanied by digestive 
disturbances, weakness, anemia, dyspnea, cardiac palpation, head- 
ache, vertigo and impairment of sight. The urine is scanty, of 
low specific gravity, contains much albumin with hyaline and 
large granular casts and sometimes, oil globules, fatty casts and 
red blood cells are found. This disease is frequently first diag- 
nosed by an insurance examiner causing the rejection of an ap- 
plicant on account of albumin in the urine, when such a condi- 
tion has not even been suspected. 

DIFFERENTIAL DIAGNOSIS: CJiroiic Pamichymafous 
Nephritis must be dift'erentiated from the acute form and also 
from chronic interstitial nephritis and the diagnosis is best made 
30 



466 DISEASES OF THE KIDNEYS AND BLADDER 

from the history of the disease and an examination of the urine. 
In acute and chronic parenchymatous nephritis, the amount is 
scanty, while in chronic interstitial nephritis a large amount is 
voided daily and contains only a trace of albumin. Large granu- 
lar casts are characteristic of the chronic form of parenchymatous 
nephritis and while either of the other forms may show granular 
casts, they are usually narrow and sm.all. Fatty and waxy casts 
with oil globules are commonly found in chronic parenchymatous 
nephritis. 

COMPLICATIONS peculiar to acute parenchymatous 
nephritis are also present in the chronic form, together with nu- 
merous others such as acute exacerbations, serous effusion into 
the tissues, convulsions and uremia, valvular disease of the heart, 
apoplexy and meningitis. 

HOUSE CONFINEMENT when chronic parenchymatous 
nephritis is existing does not occur until near the termination of 
the life or when an acute exacerbation of the disease takes place. 
If an acute inflammation is excited, house confinement lasts from 
I to 2 weeks, when the occupation is again resumed unless the 
kidneys are so badly diseased that confinement to the house per- 
sists until death occurs, which usually takes place within 2 to 4 
or 6 weeks. 

TOTAL DISABILITY is seldom present in this disease un- 
til an acute attack of uremia occurs, when from 2 to 3 or 4 weeks 
may be necessary provided the individual is able to return to his 
occupation. Usually, however, when this complication ensues the 
kidneys are so badly diseased that total disability persists from 
the beginning of the attack of uremia until death ends the life and 
this may require from, i to 3 or 6 months; depending on the con- 
dition of the kidneys, the financial position of the individual, mode 
of treatment, etc. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if pa3^able by the policy after the termination of house con- 
finement may require any number of weeks within the limit of 
the policy. If the kidneys are not so badly diseased that the in- 
dividual becomes strong enough to get out of the house after 
having suffered an attack of uremic poisoning, from i to 2 or 4 
months are generally sufficient. 

EFFECTS: Chronic parenchymatous nephritis almost in- 
variably terminates by death within six to eighteen months after 
it is first recoe-nized. Therefore, if an individual is suffering 
with this form of kidney degeneration, insurance of all kinds must 



I 



CHRONIC INTERSTITIAL NEPiHlRITIS 467 

be refused. When a claim is paid for this disease, insurance 
companies cancel all accident and health insurance. Life insur- 
ance, however, in such cases should be kept in force by the in- 
dividual, as it is only a question of time until death occurs. 

CHRONIC INTERSTITIAL NEPHRITIS 

SYNONYMS: Chronic Bright's disease; interstitial nephri- 
tis; diffuse nephritis; sclerosis of the kidneys; red granular kid- 
ney; contracted kidney; gouty kidney. 

INFORMATION: Chronic interstitial nephritis is a long 
standing inflammation of the connective tissue of the kidneys 
which causes a hardening and contraction of the whole organ. It 
is more common between the ages of forty and sixty years and is 
more frequently met with in males than in females. It is caused 
by alcoholism, syphilis, chronic lead poisoning, chronic cystitis, 
cardiac and liver diseases, and is sometimes a primary inflamma- 
tion. 

SIGNS AND SYMPTOMS: This disease, Hke parenchyma- 
tous nephritis is insidious in onset and is often first diagnosed by 
a life insurance examiner. The signs and symptoms are vague 
and may be referable to the heart, blood vessels, gastro-intestinal 
tract, the brain or kidneys. When the heart is involved, the ac- 
tion is forcible with high arterial tension, the second aortic sound 
is accentuated and hardening of the arteries is noticeable; pain 
in the cardiac region with dyspnea and palpitation occur. Gas- 
tric disturbances result in loss of appetite, chronic dyspepsia and 
sometimes nausea and vomiting. Attacks of vertigo with head- 
ache, drowsiness, convulsions and apoplexy are frequent. The 
urine is pale, excessive in amount, of low specific gravity, and 
usually contains a trace of albumin, but at times this is absent; 
hyaline casts are present together with narrow pale, granular 
casts in somiC cases. 

DIFFERENTIAL DIAGNOSIS between this disease and 
chronic parenchymatous nephritis is generally made by an exam- 
ination of the urine, although the history and evidence of the in- 
volvement of other organs assist in determining when a chronic 
interstitial nephritis exists. 

Chronic Parenchymafoiis N'cpJirifis shows a small quantity of 
urine of high specific gravity, dark in color with nuich albumin, 
large hyaline and granular casts, while interstitial nephritis shows 
an excessive amount of pale lU'ine, of low specific gravity, little or 



468 DISEASES OF THE KIDNEYS AND BLADDER 

no albumin, with narrow hyaline casts, and when granular casts 
are found they are narrow and small. Interstitial nephritis is 
usually complicated by involvement of the heart with accentua- 
tion of the second aortic sound and hardening of the arteries, and 
this is not so common in the other form. 

COMPLICATIONS : Apoplexy is a common sequelae when 
this disease is existing and is the result of a break in the hard- 
ened arteries. 

Organic Disease of the Heart resulting in valvular changes fre- 
quently accompanies this disease, sometimes preceding it, while 
in other cases it follows. 

Uremia may result at any time during the course of this dis- 
ease, but occurs less often than when chronic parenchymatous 
nephritis is existing. 

Pneumonia, Bronchitis and Pleurisy are frequent complications 
and often produce a fatal result. 

Pericarditis when it occurs in an individual suffering with 
this disease is almost invariably fatal. 

All of the above complications produce or prolong an already 
existing disability according to the physical condition of the per- 
son suffering with the disease, the surroundings and the ability to 
secure proper treatment. 

HOUSE CONFINEMENT in this disease does not exist 
until near the termination of the attack unless it is produced by 
an acute exacerbation or one of the various complications, and 
when due to an acute attack of inflammation usually lasts from i 
to 2 or 3 weeks. When a complication causes house confinement, 
the time is governed by the nature of the complication and if at 
all severe, death generally terminates the case in i to 2 weeks. 

TOTAL DISABILITY in chronic interstitial nephritis does 
not take place until an acute inflammation supervenes or a com- 
plication causes loss of time. In the first instance from 2 to 3 
weeks are usually ample for an individual to sufficiently recover 
so that part of the duties may be resumed. When a complication 
causes total disability the time is governed by the complication, 
and this may be prolonged from i to 2 or 3 weeks if the illness 
ends during cold and wet weather and the individual is getting 
near the end of Hfe. As this form of nephritis advances, total dis- 
ability may begin without an acute attack and in such cases it per- 
sists until death terminates the case, and this ma}^ require from i 
to 3 or 6 months. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 



CYSTITIS 469 

if payable by the policy after the ending of house confinement 
may require from i to 2 or 3 weeks in some cases, but this form 
of disability — even if payable by the policy — is not often de- 
manded. 

EFFECTS : If chronic interstitial nephritis is known to ex- 
ist or even suspected, an insurance company will not issue any 
kind of insurance on such a person and if life or health insurance 
is carried by an individual suffering with this disease and the fact 
becomes known to the company issuing the policies, they will be 
cancelled at once. 

CYSTITIS 

SYNONYMS: Catarrh of the bladder; inflammation of the 
bladder. 

INFORMATION: Cystitis or inflammation of the bladder 
is due to infection and follows a number of causes. Acute cystitis 
is usually a complication of some disease of the genito-urinary 
tract, such as urethral infection, cancer, tuberculosis, enlarged 
prostate, stone and various growths in the bladder. It may also 
be due to exposure, kicks or blows over the bladder region, long 
retention of urine, traumatism from the passing of a catheter, the 
eHmination of drugs, — most notably cantharides and secondary 
to infectious fevers. Chronic cystitis exists when a constant irri- 
tation is present, such as produced by a stone in the bladder, en- 
larged prostate gland, etc. 

SIGNS AND SYMPTOMS of acute cystitis are usually sud- 
den in onset, beginning with a feeling of depression, a constant 
desire to urinate with the frequent passage of small quantities of 
urine accompanied by a burning pain. There is loss of appetite, 
headache, rigors and each micturition is accompanied by vesical 
tenesmus. An examination of the urine shows it to be thick and 
cloudy, usually acid in reaction and containing albumin, mucus, 
pus and sometimes blood cells with a large number of bacteria. 
More or less elevation of temperature is present and nervousness 
generally accompanies the disease. Chronic cystitis may follow 
the acute form or may develop gradually from some constant irri- 
tation inside the bladder. It is unaccompanied by elevation ot 
temperature, while pain and tenderness, if present, are usually 
slight. The urine in this condition is turbid, of bad odor and on 
standing shows a heavy precipitate of mucus, pus and often blood 
with a great excess of phosphates. 



wm 



470 DISEASES OF THE KIDNEYS AND BLADDER 

DIFFERENTIAL DIAGNOSIS: Pyelitis is sometimes 
diagnosed as cystitis, but in this disease the dull pain over the 
kidneys is transmitted along the ureters and while frequent mictu- 
rition occurs, it is not complicated with vesical tenesmus. The 
urine is turbid, but acid in reaction and contains renal epithehum; 
in addition to the above, systemic symptoms due to the presence 
of pus frequently present themselves. 

COMPLICATIONS: Venereal Disease often complicates an 
attack of cystitis; the latter being due to the spread of this infec- 
tion. When cystitis follows a venereal infection, an insurance 
company would not pay indemnit}^ under a disability policy if it' 
was known that such a condition existed or caused the cystitis. 

Tuberculosis of the Bladder Walls frequently produces a cys- 
titis and when this condition is present the disease will generally 
be found existing in some other part of the body. If an individual 
suffering from a cystitis which was due to or complicated by a tu- 
berculous condition in some other part of the body, would claim 
indemnity for this disease and had only carried a disabilit}^ policy 
a short time, an insurance company would not recognize the 
claim as the tuberculosis would be existing before the policy was 
taken out or became in effect. 

Cancer of the Walls of the Bladder is generally complicated 
vvdth a cystitis and when this disease is existing, unless a disabil- 
ity policy has been in force a number of months, an insurance 
company would not be liable for the disability caused by the cys- 
titis, for the reason that the cancer would probably have been ex- 
isting before the poHcy was issued. 

HOUSE CONFINEMENT in mild uncompHcated cases of 
cystitis lasts from 5 to lo days and when a severe infection has 
taken place, from 2 to 3 weeks are necessary. If the termination 
of the inflammation occurs during cold and wet weather, house 
confinement is generally prolonged from 2 to 5 days. When this 
disease exists as a complication or follows a pre-existing disease, 
it usually increases disabihty from i to 3 weeks, according to the 
severit}^ of the inflammation. 

TOTAL DISABILITY in the average case of cystitis which 
is not of venereal origin, lasts from 10 to 14 days; this time de- 
pending on the severity of the disease, the advantages of treat- 
ment, the condition and age of the individual. Sometimes, how- 
ever, a cystitis seems intractable, in which case total disability 
may last from 3 to 5 or 7 weeks. Usually, however, in these cases 



PYELITIS 471 

there is some complication which prolongs the period of disabil- 
ity. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is not often required, for the reason that an individual who 
has suffered from this disease can generally return to his occu- 
pation as soon as house confinement is ended. 

EFFECTS : An individual suffering from an attack of acute 
uncomplicated cystitis is insurable for all kinds of insurance from 
two to four months after complete recovery. Whenever a claim 
is received alleging cystitis as the cause of disability, it is very im- 
portant to an insurance company that it is not venereal in origin, 
as very few policies pay disability as the result of a specific infec- 
tion. If a history of this disease exists and it is known that it was 
venereal in origin, very few insurance companies would refuse to 
issue all kinds of insurance unless the moral hazard was extremely 
bad in other respects. If the disease becomes chronic, such a per- 
son is uninsurable for any kind of a policy. 

PYELITIS 

SYNONYMS: Suppurative nephritis; pyelo-nephritis. 

INFORMATION: Pyelitis is an acute catarrhal inflamma- 
tion involving the pelvis of the kidney and follows exposure, cys- 
titis and urethritis, the excretion of irritating drugs, specific fev- 
ers and stone in the kidney. 

SIGNS AND SYMPTOMS: Simple catarrhal pyelitis be- 
gins with a dull pain over the region of the kidneys followed by 
chilliness, slight fever, frequent micturition with the passage of 
urine which is acid or neutral in reaction, of a milky white appear- 
ance and when allowed to stand a heavy sediment containing mu- 
cus, epithelial cells, casts and pus corpuscles are precipiated. If 
a catarrhal pyelitis becomes suppurative, pain and tenderness are 
increased in the lumbar region and symptoms of a septic condition 
supervene. 

DIFFERENTIAL DIAGNOSIS: Cysfifis is differentiated 
from pyelitis by the absence of lumbar pain and alkaline reaction 
of the urine; also by the microscope which shows the absence of 
renal epithelium and the presence of bladder cells. 

Perinephritic Abscess causes a circumscribed swelling in the 
lumbar region and terminates in the evacuation of the abscess. 



472 DISEASES OF THE KIDNEYS AND BLADDER 



It is accompanied by pain which is increased by motion or pres- 
sure, hectic symptoms and normal urine. 

Tttherculous Pyelitis generally has a history of tuberculosis in 
some other part of the body and the microscope shows the ba- 
cillus of tuberculosis in the urine. 

Calculous Pyelitis is sudden in onset and is accompanied by 
sharp pain which radiates down the ureters and is characterized 
by the passage of bloody urine. 

The diagnosis of diseases affecting one or both kidneys is 
best made at the present time by the use of a cystoscope and the 
catheterization of each ureter separately. This method of diag- 
nosis gives good results in the hands of experts and should be 
used in all obscure cases of diseases of the kidneys. 

COMPLICATIONS : Uremia is a frequent complication of 
pyelitis, when both kidneys are more or less involved. If this 
condition ensues, death often takes place and if recovery follows, 
disability is greatly prolonged. 

HOUSE CONFINEMENT in cases of pyelitis involving 
one kidney only and in which there is no obstruction to the outlet 
of pus, requires from i to 2 and sometimes 3 weeks. If both kid- 
neys are involved the termination is usually fatal and occurs 
within 2 to 3 weeks. 

TOTAL DISABILITY in uncomplicated cases of pyelitis 
involving one kidney usually lasts from 2 to 3 weeks in all classes 
of risks. If both kidneys are affected total disability may last 
from I to 3 weeks only and be terminated by death. When re- 
covery takes place the period of disability is uncertain, sornetimes 
lasting from 3 to 4 or 6 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment sometimes requires from 3 to 6 weeks in cases of this dis- 
ease. 

EFFECTS : Individuals with a history of an attack of pye- 
litis involving one kidney, would not be insurable for life or health 
insurance until at least one year after complete recovery and a 
medical examination would show normal urine and absence of any 
systemic disease. If both kidneys were involved and recovery 
followed, such a person would not be insurable for life or health 
insurance until two to four years after complete recovery and 
subject to the above conditions of an examination. Accident in- 
surance in either case, however, would be written from two to 



^ 



4 



RENAL CALCULI 



473 



three months after complete recovery by the majority of casualty 
companies. 

RENAL CALCULI 

- SYNONYMS: Nephro-lithiasis; renal colic; gravel. 

INFORMATION: The formation of renal calculi in the 
pelvis of the kidney is due to the precipitation of various solid 
constituents of the urine and is more common in females than in 
males. It occurs at all ages, but is more frequent between forty 
and fifty years of age. Renal calculi vary in size from coarse sand 




Fig'. 111. — Kidney showing- calculi lodged in the calices of the 
pelvis (natural size). (Greene and Brooks). 



to a large bean and are composed of a central nucleus, which is 
surrounded by layers of different material causing a stratified ap- 
pearance on cross section. They are composed of uric acid, 
urates and oxalate of lime and phosphates; occurring more fre- 
quently in the above described order. 

SIGNS AND SYMPTOMS: Renal calculi may exist in the 
pelvis of one or both kidneys for an indefinite time without caus- 
ing any inflammation and therefore such a condition is unknowti. 



474 DISEASES OF THE KIDNEYS AND BLADDER 

When an inflammation is set up for any reason and nature at- 
tempts to expel these concretions, severe and intense pain comes 
on suddenly and this is transmitted down the ureters and is ac- 
companied by tenderness in the lumbar region. The face be- 
comes pale and pinched, while the body is cold and covered with 
perspiration. The specific gravity of the urine is above normal, 
it is slightly albuminous, contains much blood with epithelium 
and a few long, narrow, hyaline casts; pus cells may or may not 
be present. 

DIFFERENTIAL DIAGNOSIS : Colic due to gall-stones 
is sometimes mistaken for renal colic, but in this disease the pain 
radiates to the shoulder, the gall-bladder is tender and enlarged 
and can be palpated in thin subjects, jaundice is common, while 
the urine is negative and sometimes stones are found in the stools. 

Appendicitis may be diagnosed as an attack of renal calculi, 
but in the former there is a distinct swelling in the lower right 
iliac region, with rigidit}^ of adjacent muscles, localized pain and 
tenderness with absence of pain in the region of the kidneys and 
normal urine. 

Movable Kidney is distinguished by pain of a dragging or 
pulling character and referred to either side of the median line, 
with evidence of a movable tumor in the abdomen. If the ureter 
becomes twisted, the urine is scanty and as the kidney slips back 
into place the discharge becomes copious. 

COMPLICxA^TIONS: Suppurative Pyelitis may complicate 
a stone in the kidney; in which event disability is prolonged, and 
if both kidneys are involved a fatal termination commonly occurs. 

HOUSE CONFINEMENT seldom exists in persons suffer- 
ing with renal calculi except when an attack of renal colic occurs. 
In such cases an attack of colic does not cause house confine- 
ment, but the laceration and tearing of the ureter by a stone in 
the passage from the kidney to the bladder, together with the 
shock due to the severe pain, causes house confinement of from 
I to 3 or 7 days. Should the stone in its passage through the 
ureter become lodged at any point and an operation be necessary 
for its removal, house confinement lasts from 4 to 6 or 8 weeks 
after the date of operation. 

TOTAL DISABILITY is rarely payable to individuals suf- 
fering with renal calculi unless an attack of renal colic occurs and 
if this is uncompHcated and the pohcy pays for a period of dis- 
ability when less than seven da3^s duration, from 3 to 5 days are 
usually sufficient. If an operation is performed for the removal 



UREMIA 475 

of the stone, from 6 to 8 weeks of this form of disabiUty may be 
necessary in all classes of risks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if allowed by the policy after the termination of house confine- 
ment, is not payable to persons suffering with an attack of renal 
colic which does not necessitate an operation. When an opera- 
tion has been performed, from 2 to 4 weeks of this form of indem- 
nity may be demanded. 

EFFECTS : If a history of renal colic exists in any individual 
or a diagnosis of renal calculi has been made by a competent phy- 
sician, life or health insurance must be denied a person suffering 
with such a condition. Accident insurance would be written, 
however, by some companies from one to two months after such 
an attack and apparent recovery, but it is questionable if the is- 
suance of any kind of insurance is good underwriting. 

UREMIA 

SYNONYMS: Uremic poisoning; uremic intoxication; ure- 
mic convulsions; uremic coma. 

INFORMATION: Uremia is the name applied to a condi- 
tion which results when the function of the kidneys is interfered 
with for any cause and the poisons which they eliminate are re- 
tained and disseminated throughout the system. During the 
course of an acute or chronic Bright's disease, these symptoms 
may develop slowly or suddenly. This condition may also occur 
when the kidneys are tuberculous or cancerous. It sometimes 
follows operations and also child-birth. 

SIGNS AND SYMPTOMS: An attack of uremic poison- 
ing usually begins with diminution in the amount of urine voided, 
headache, vertigo, edema in different parts of the body and sud- 
den blindness, with convulsions and coma. Sometimes these at- 
tacks are accompanied by nausea and vomiting, elevated temper- 
ature and increase in pulse and respiration. 

DIFFERENTIAL DIAGNOSIS between unconsciousness 
due to uremia and other conditions which may produce it, is im- 
portant and is fully considered under Concussion of the Brain. 

COMPLICATIONS: Uremia is usually a complication of 
some preceding disease and when it exists, it is generally good 
evidence that one or both kidneys are badly diseased, provided 
it does not occur during an acute attack of nephritis. 

HOUSE CONFINEMENT in cases snfforino- with uroniic 



^^^mv^HV 



476 DISEASES OF THE KIDNEYS AND BLADDER 

poisoning* is uncertain and depends on the condition of the kid- 
neys, the physical strength of the individual, the length of time 
the poison has been retained in the system and also the amount. 
A fatal termination often takes place within 3 to 7 days and if this 
does not occur but a partial or complete recovery follows, house 
confinement may last from i to 3 weeks or more; this time being 
governed by the physical condition and the extent to which the 
kidneys are diseased. 

TOTAL DISABILITY in cases which terminate fatally 
lasts from 3 to 7 days and when recovery takes place from 3 to 6 
weeks are usually required for this form of disability. Attacks 
of uremia occurring during the winter months prolong the above 
period of disability i to 2 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
when payable under the terms of the policy after the termination 
of house confinement may require from i to 2 or 3 wxeks; this 
time depending on the age, severity of the attack and weather 
conditions. 

EFFECTS : Individuals with a histor}^ of an attack of uremic 
poisoning are generally those who have suffered from an acute 
attack of nephritis or are suffering with the chronic form. In 
the former, however, life or health insurance cannot be written 
until six to twelve months after complete recovery and several 
examinations of the urine extending over a considerable time 
have been made and this excretion found to be normal. Accident 
insurance can be issued in this class of cases from two to three 
months after complete recovery and a medical examination has. 
shown the urine to be normal. In chronic cases of nephritis all 
forms of insurance must be denied a person suffering with such 
a disease. 



CHAPTER XIX 

FEVERS 

CEREBRO-SPINAL FEVER 

SYNONYMS: Epidemic cerebro-spinal fever; epidemic cere- 
bro-spinal meningitis; cerebro-spinal typhus fever; spotted fever. 

INFORMATION: Cerebro-spinal fever is a malignant dis- 
ease, usually occurring in epidemics and more frequent in the 
winter and spring months. The young are more often affected 
and the period of incubation is unknown. 

SIGNS AND SYMPTOMS: This disease is divided into 
three forms, the abortive, the common and the fulminate; the 
signs and symptoms being the same, except that the degree of 
severity is more pronounced in one than the other. An attack 
generally begins suddenly with a chill, severe headache, vertigo, 
nausea and vomiting. This is followed in a few hours by excru- 
ciating pain and rigidity in the muscles of the head, back and 
limbs, resulting in retraction of the head and back, thus produc- 
ing opisthotonos and inability to straighten the leg when in the 
recumbent posture. Intolerance of light, with impaired taste, 
smell and hearing, hyperesthesia, with convulsions and delirium 
follow. The temperature in this disease is markedly irregular 
and gives no assistance in making the diagnosis. A peculiar pur- 
puric rash appears from the first to the fifth day in the majority of 
cases and the tache cerebrale is usually obtainable. 

DIFFERENTIAL DIAGNOSIS is positively made by lum- 
bar puncture of the spinal cord. If this disease exists the fluid 
is cloudy and in some epidemics the diplococcus is found. 

Typhoid Fever may be mistaken for cerebro-spinal fever in 
the early stages, but this disease is gradual in onset and has been 
preceded by a period of malaise. It is characterized by diarrhea, 
tympanitis, enlarged spleen, rose spots, characteristic tempera- 
ture curve and the Widal reaction is usually obtainable. 

Typhus Fever in the early stages niay 1x^ confused with cere- 
bro-spinal fever, but in typhus fever the eruption does not appear 
until the fifth to the seventh day and is known as a measly erup- 

477 



478 FEVERS 

tion which does not disappear on pressure. Great prostration ex- 
ists and absence of pain in the back and Umbs and opisthotonos 
is noticed. 

Small-Pox may cause an error in diagnosis during the first 
few days, as this disease is characterized by severe headache and 
lumbar pains with vomiting and a rash. The rash, however, first 
shows itself on the forehead and wrists by small shot-like particles 
under the skin. 

Tuberadons Meningitis is slow in onset, often extending over 
a considerable time before it begins to resemble cerebro-spinal 
fever. It is not epidemic and no eruption appears, there is only 
a slight tendency to opisthotonos and a careful examination gen- 
erally shows the existence of a tuberculous process in some other 
part of the body. 

Complications involving the heart and lungs occur frequently, 
the most common being pneumonia, which may be present early 
or late in the disease and endocarditis and pericarditis. 

SEQUELAE are common after recovery from an attack of 
this disease. Persistent headache from chronic meningitis fre- 
quently remains a considerable time. There may be defective 
hearing from a suppuration of the internal or middle ear, impaired 
vision from inflammation involving the cornea, retina or optic 
nerve, imbecilit}^ chronic hydrocephalus and different forms of 
paralysis. 

HOUSE CONFINEMENT in the abortive form lasts from 
3 to 7 days, when convalescence is established sufficiently to per- 
mit the individual being outside. In the common form, house 
confinement of from 2 to 4 or 6 weeks is necessary, this depend- 
ing on the severity of the infection and the physical condition. 
The fulminate form usually produces death within i to 2 days and 
therefore house confinement does not last longer than this time, jl 

TOTAL DISABILITY in abortive cerebro-spinal fever lasts ' 
from": to 2 or 3 weeks; the common form from 4 to 8 or 12 weeks 
and in the fulminate form from i to 2 or 3 days only. If complete 
recovery does not take place after an attack of this disease and 
imbecility results, total disability may be permanent and require 
the limit of time allowed by the policv. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment may be necessary and usually requires from 3 to 6 weeks, 
but in some cases the limit of the policy must be allowed when a 
full mental recovery does not take place. 



DENGUE 479 

EFFECTS : Individuals having suffered an attack of cere- 
bro-spinal fever in childhood in which recovery has taken place 
and no bad effects are noticeable, are insurable for all kinds of 
insurance in adult life. If the disease occurs later in Hfe and ap- 
parent complete recovery follows, life or health insurance cannot 
be issued until two to three years after the attack and a medical 
examination shows the recovery to have been complete. Acci- 
dent insurance in such cases, however, can be safely written from 
six to nine months after recovery follows the termination of the 
disease. 



DENGUE 

SYNONYMS: Break-bone fever; dandy fever; neuralgic 
fever. 

INFORMATION : Dengue is an acute febrile disease, oc- 
curring in epidemics and seldom seen except in hot climates. The 
cause is unknown, but it is supposed to be due to an undiscovered 
microbe. 

SIGNS AND SYMPTOMS: This disease is sudden in on- 
set beginning with headache, backache, pain in all the muscles 
and joints of the body with nausea, vomiting, high fever running 
from ioi° to 103° F, and a rash which resembles scarlatina. 
These symptoms persist for from a few hours to several days, 
then an intermission of one to two days follows, when the symp- 
toms recur and last from one to two or three days. Relapses are 
frequent and prolong the period of disabilitv. 

DIFFERENTIAL DIAGNOSIS: .iciifc Articular Rhcinmt- 
tisni is often mistaken for dengue, but in this disease one or more 
joints become affected with redness, swelling and intense pain 
and after a period of time other joints are involved: acid sweats 
occur and the duration is much longer. 

Scarlet Fever or Measles are sometimes diagnosed for dengue 
but in either of these diseases there is absence of pain in the nnts- 
cles and joints of the bod3% and symptoms characteristic of the 
two diseases soon show themselves sufficiently for a proper diag- 
nosis. 

COMPLICATIONS involving the nervous systoni arc nio-^r 
frequently seen following this disease and when thoy occur dis- 
ability is prolonged an uncertain time. 

HOUSE CONFINEAIENT lasts from t to 2 weeks in the 



480 FEVERS 

average case, but on account of the frequency of relapse, this 
time may be extended and require from 2 to 3 or 4 weeks. 

TOTAL DISABILITY in all classes of risks usually lasts 
2 weeks, provided a relapse has not occurred; each relapse pro- 
longs this period of disability from 3 to 7 davs. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy in addition to house confinement, gen- 
erally demands from i to 2 or 3 weeks. 

EFFECTS : All forms of insurance can be safely issued to 
individuals who have suffered from this disease, from two to four 
months after complete recovery. 

INTERMITTENT MALARIAL FEVER 

SYNONYMS: Intermittent fever; swamp fever; ague; chills 
and fever. 

INFORMATION : Intermittent malarial fever is a paroxys- 
mal fever caused by the Plasmodium malarise of Laveran, which 
is found in the blood of those suffering from the disease. All 
forms of malarial fever are caused by the bite of certain mos- 
quitoes and all ages and both sexes are equally affected. 

SIGNS AND SYMPTOMS occur in paroxysms and consist 
of three stages — the cold, hot and sweating — in the order named. 
The first or cold stage begins with chilliness, aching in the limbs, 
yawning, headache and nausea and this condition finally develops 
in a pronounced chill in which the surface of the skin is pale and 
cold, chattering of the teeth is present and is accompanied with 
thirst, while the temperature is elevated, reaching as high as 102* 
to 104° F. This condition may persist from a few minutes to one- 
half hour or more, when it is superseded by the hot stage which 
begins gradually; the skin instead of being cold becomes hot and 
flushed, the eyes injected, with headache, nausea, thirst and high 
temperature with scanty and dark colored urine. This stage lasts 
from one to five or eight hours and in turn is followed by the 
sweating stage which also begins gradually, the sweat appearing 
on the forehead and slowly spreading over the entire surface of 
the body. After the perspiration is fully established, headache | 
and other pains grow less violent, the fever gradually subsides, 
and finally the sweating stage which lasts from three to five hours 
terminates by sleep, when the individual awakens much re- 
freshed. The temperature becomes normal and remains so until 
another paroxysm takes place, when the same chain of signs and 

i! 



PLATE XJV^ 



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10 



J 



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12 



J3 



14 






15 



W 



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M 



IS 



20 



2J 



22 



B3 



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24- 



2S 



26 



27 






Various Forms of Malarial Parasites (Thayer and Hewetson). 

Figs. 1-10 inclusive, tertian organisms; Figs. 11-17 inclusive, quartan organisms; Figs. 18- 
27 inclusive, estivo-autumnal organisms. 

Fig. 1. — Young hyaline form; 2, hyaline form with beginning pigmentation; 3. pigmented 
form; 4, full-grown pigmented form; 5, 6, 7, 8, segmenting forms; 9. mature pigmented lorm; 
10, flagellate form. 

Fig. 1. — Young hyaline form; 12, 13, pigmented (orms ; 14, iull\ de\ eloped lorm: 15. 10. 
segmenting form ; 17, flagellate form. 

Figs. 18, 19, 20. — Ring-like and cross-like hyaline tonus ; 21. 22. pigmented lorms : 2o. 24- 
segmenting forms ; 25, 26, 27, crescents. 



I 



INTERMITTENT MALARIAL FEVER 481 

symptoms are repeated. These attacks follow one another ac- 
cording to the variety of the malarial fever, either the quotidian, 
the paroxysm occurring daily; tertian every other day; quartan 
every fourth day; octan every seven days; duplicating quotidian 
or tertian when two paroxysms occur on the day they are due, 
and several other rare forms. The spleen is always enlarged dur- 
ing an attack of malarial fever." 

DIFFERENTIAL DIAGNOSIS : Intermittent Malarial Fever 
should not be hard to diagnose, for the reason that a microscope 
always shows the hematozoon present during an attack. 

Hectic Fever is sometim.es mistaken for malarial fever, but 
when this condition exists the spleen is not enlarged and absence 
of the characteristic malarial organism from the blood is noted. 

Neurasthenia in which nervous chills occur, is not followed 
by increased temperature and sweating. 

SEQUELAE: Pernicious Malarial Fever may supervene in 
individuals who suffer from attacks of intermittent fever. If this 
condition follows, total disability is not only greatly prolonged, 
but a fatal termination is usually the result. 

HOUSE CONFINEMENT in intermittent fever depends 
on the occurrence of the paroxysm. In the quotidian form in 
which a paroxysm occurs daily, house confinement of from 3 to 
7 or 10 days may be necessary before the disease is under control. 
The tertian and quartan forms in which the paroxysm occurs on 
the second or fourth day may or may not cause house confine- 
ment, according to the severity of the infection and the physical 
condition of the individual. House confinement in such cases, if 
it occurs, does not last more than i to 2 days at a time and is sep- 
arated by an interval in which the sufferer is not confined to the 
house. 

TOTAL DISABILITY like house confinement depends on 
the number and the time of occurrence of the paroxysms. In the 
quotidian and tertian forms, total disability may last from i to 
2 weeks. In the quartan form, total disability lasts from i to 2 
days at a time and is followed by a period in which the occupa- 
tion can be resumed for i to 2 days. This form seldom causes 
disability which is covered by a health or disability policv. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is sometimes necessary in persons who suffer from the quo- 
tidian or tertian form of intermittent fever. In such cases from 



482 



FEVERS 



I to 2 weeks of this form of disability may be required for severe 
attacks of either of these varieties of intermittent fever. 

EFFECTS : AA'hen a history of repeated attacks of intermit- 
tent fever exists in an individual, such a person is not insurable 
for health insurance at any time without a waiver eliminating in- 
demnity for malaria. Life and accident insurance might be ac- 
cepted by some companies with such a history, but it is question- 
able if a person with chronic malaria is insurable for these forms 
of insurance. If an individual has suffered with malaria and re- 
covery has been complete, all forms of insurance can be safely 
written from six to twelve months after the termination of the 
disease. 

REMITTENT FEVER 

SYNONYMS: Estivo-autumnal fever; bilious fever; bilious 
remittent fever; typho-malarial fever; marsh fever; jungle fever. 

INFORMATION: Remittent fever is a paroxysmal fever 
in which the temperature is lowered during the interval, but 
never becomes normal. It is due to a specific organism, the Plas- 
modium malarise of Laveran. The disease is more commpn in 



Dsrt 




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1 


1 


ica 

107 


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M|E 


mIe 


MiE 


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m!e 


MJE 


MJE 


m[e 


mIe 


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m'e 


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m!e| 

; lOS 

107 


105 
104 
103 

loa 

101 
100 
99 


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n^\\:i\rr:^''\!:i^^^^^-^ 


97M 1 j |— j !--i 1 ' 1 ' i ■ 1 1 1 ! 1 ' 1 i i ' 1 ' 1 i 1 1 T~^ 5' 



Fig'. 112. — Temperature chart of remittent fever. (Paul). 

tropical countries with marshy districts where it is found at all 
seasons of the year and where it assumes its most severe form. 

SIGNS AND SYMPTOMS of remittent fever depend on 
the different stages. The cold stage is usually not as well 
marked as in intermittent fever, the chill being less severe and 
only a slight elevation of temperature occurring, while pain in 
the head and throughout the body is only slight. This stage^ 



REMITTENT FEVER 483 

however, may be very marked when an unusually severe infection 
has taken place. The hot stage follows the preceding one and is 
marked by fever, the temperature rising to 104° or 106° F., it is 
accompanied by an increased pulse rate, flushed face, intense 
headache with pain in the limbs, persistent vomiting, the passage 
of small amounts of high colored urine and in some cases de- 
Hrium is seen in this stage which lasts from six to twenty-four 
hours. Following this, the sweating stage comes on and persists 
for two to twelve hours or more, during this period the headache 
and vomiting subside and the temperature falls several degrees 
but not to the normal point, usually stopping between 99° to loc'' 
F. These three stages are then followed by the remission in which 
the signs and symptoms of a mild pyrexia are present, this remis- 
sion lasting from two to six or twelve hours and sometimes 
longer, when the above routine is again commenced, minus the 
cold stage in the majority of cases, the second part of the disease 
usually commencing with the hot stage. In this form of malaria, 
the spleen is enlarged, the liver swollen and congested and the 
characteristic organism is found in the red corpuscles. 

DIFFERENTIAL DIAGNOSIS : Intermittent Fever is diag- 
nosed from remittent fever by the fact that between the par- 
oxysms a distinct intermission occurs in which the temperature 
becomes normal; also in intermittent fever each paroxysm com- 
mences with a chill, while in the other form after the first par- 
oxysm, the chill is generally omitted. In remittent fever the in- 
dividual is ill during the remission, while in intermittent fever he 
is apparently well. 

TypJioid Fever is often mistaken for remittent fever, but in 
this disease there are marked abdominal symptoms such as tym- 
panites, rose-colored spots, the Widal reaction in the blood and 
absence of the hematozoa from the blood as found in remittent 
fever. Typhoid fever has a temperature record which is entirely 
different from that of remittent fever. 

Yellow Fever is differentiated from remittent fever by the 
high fever with which this disease commences, a peculiar and 
characteristic odor which is emitted, the single remission in the 
temperature which is followed by jaundice of the skin, black 
vomit and hemorrhages into other parts. Examination of the 
blood shows the absence of the characteristic Plasmodium ma- 
larice. 

SEQUELAE: Malarial Cachexia may follow repeated at- 
tacks of remittent fever. If this condition supervenes, total dis- 



484 FEVERS 

ability is prolonged indefinitely and in some cases is terminated 
by death. 

HOUSE CONFINEMENT does not exist in mild cases of 
this disease; the individual remaining in the house a few hours 
at a time during the hot stage. In more severe forms, house con- 
finement lasts from 7 to lo days and this may sometimes be in- 
creased from 3 to 7 days when the attacks are unusually severe 
and long and the remission is less marked than usual. 

TOTAL DISABILITY in mild cases of remittent fever oc- 
curring in the temperate zone, lasts from i to 2 weeks. If the 
disease occurs in the tropics and is severe, from 2 to 4 weeks are 
necessary; this time depending on the number of times the par- 
oxysms are repeated and the character of the remission. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is not often necessary in mild attacks of remittent fever in 
the temperate zone, but in the tropics from i to 2 weeks of this 
form of disability are generally required after a severe attack. 

EFFECTS : Individuals living in hot climates with a history 
of having suffered one or more attacks of remittent fever are not 
insurable for life or health insurance until six to twelve months 
after the termination of an attack, and good underwriting would 
demand a waiver on a health policy eliminating disability for this 
disease. Accident insurance can be written from one to two 
months after the termination of an attack. 

PERNICIOUS MALARIAL FEVER 

SYNONYMS: Malignant intermittent fever; mahgnant re- 
mittent fever; congestive fever; congestive chill. 

INFORMATION: Pernicious malarial fever is a mahgnant 
form of this disease which results in death within a short time. It 
represents the severest form of poisoning due to the character- 
istic organism and is not common except in the tropics. 

SIGNS AND SYMPTOMS show themselves according to 
the variety of the disease. The cerebral form is characterized by 
delirium, stupor and coma, often resembling an attack of apo- 
plexy or acute meningitis. The thoracic variety produces dysp- 
nea, increased respiration, cough and weak pulse. The gastro- 
enteric form often accompanies the thoracic and is diagnosed by 
the nausea, vomiting, diarrhea with blood, tenesmus and thirst. 
The hemorrhagic variety is characterized by nausea, vomiting. 



PERNICIOUS MALARIAL FEVER 485 

pain in the region of the Hver and the kidneys, yellow discolora- 
tion of the skin and the passage of bloody urine. The algid form 
is recognized by the intense coldness of the skin, while the rectal 
temperature runs from 104° to 106° F. The body is covered by 
a cold perspiration, the voice is feeble, pulse slow and sometimes 
imperceptible, intense thirst is present and the mind is clear. 

DIFFERENTIAL DIAGNOSIS: Apoplexy or Meningitis 
may be mistaken for pernicious malarial fever, but in apoplexy 
more or less paralysis is noticeable and this is not present in ma- 
laria; while in meningitis there is a gradual onset accompanied 
by photophobia, diminished brain activity and sometimes pa- 
ralysis. 

Cholera in the beginning of an epidemic may be diagnosed 
for pernicious malarial fever, the gastro-enteric form of this dis- 
ease being mistaken for the early stage of cholera and the algid 
form for the later stage. 

Typhoid Fever must be distinguished from pernicious ma- 
larial fever and this is done by noting the gradual onset in ty- 
phoid, with epistaxis, tympanities and diarrhea, with absence of 
chills and vomiting. Examination of the blood serves to make 
the diagnosis clear. 

Yellow Fever is difficult of diagnosis, as both diseases occur 
in the same localities. Yellow fever, however, does not produce 
the yellow discoloration of the skin until the later stages, while 
in pernicious malarial fever it is an early sign. The vomiting of 
blood is characteristic of yellow fever and not of the other dis- 
ease. 

COMPLICATIONS: Chronic Malarial Cachexia may follow 
this disease when recovery takes place and if this form of malaria 
supervenes, disability is greatly prolonged and usually ends in 
death. 

HOUSE CONFINEMENT in the average case of this dis- 
ease seldom lasts more than from i to 2 or 3 days when the at- 
tack terminates by death. If recovery takes place, house con- 
finement of I to 2 weeks may be necessary. 

TOTAL DISABILITY is not often more than from 2 to ;, 
days except in the few cases that recover, when this form of dis- 
ability may become permanent on account of the chronic malarial 
cachexia resulting. In such cases total disability runs the limit 
of the policy. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the ternu'nation of house ooufine- 



mm 



486 FEVERS 

ment in cases that recover may require the full time as ahowed by 
a health or general disability poHcy, on account of the disease be- 
coming chronic in character. 

EFFECTS: Individuals having suffered an attack of perni- 
cious malarial fever which is followed by recovery, are not insur- 
able for any kind of insurance until at least two to three years 
have passed after the termination of the attack and no symptoms 
referable to it show themselves during that time. At the end of 
this time, an application for any kind of insurance ma^- be consid- 
ered from an individual with such a history. 

MEASLES 

SYNONYMS: Rubeola; morbilli. 

INFORMATION : [Measles is an acute, highly contagious 
and epidemic disease, more common in children but sometimes 
occurring in unprotected adults. One attack usually confers im- 
munity, but not always. The period of incubation is said to be 
from ten to fourteen days. 

SIGNS AND SYMPTOMS: The onset is gradual beginning 
with a chill, increased temperature running from ioi° to 102° F., 
headache and catarrhal symptoms referable to the nose and 
throat, with redness of the eyes and photophobia. This condition 
continues from twenty-four to thirty-six hours when a remission 
occurs in the fever, but on the third or fourth day an eruption 
consisting of dark red papules forming themselves in the shape of 
crescentic groups, appears on the forehead and face and then 
spreads over the entire body. This eruption persists from three 
to four days when it fades and sometimes is followed by a sHght 
desquamation. Black measles is a form in which hemorrhages 
in spots occur under the skin, it is more severe and is generally 
complicated with diseases of the chest. Rubella or German' 
measles is a distinct disease resembling measles, but the symp- 
toms are less marked and disability is shorter than in an attack 
of ordinarv measles. 

DIFFERENTIAL DIAGNOSIS: Scarlet Fever is diag- 
nosed from measles by the presence of high fever, rapid pulse, \ 
the early appearance of a bright red rash covering the entire 
body, the absence of catarrhal symptoms and the development of 
complications involving the ears or kidneys. | 

Rofliein may be mistaken for measles, but in this disease the' 
prodromes are slight and sometimes absent, the catarrh is not 



RELAPSING FEVER 487 

as well marked, the eruption appears at any time from the first to 
the fourth day and consists of rose-colored spots slightly elevated 
which coalesce and form irregular shaped patches. This disease 
terminates within a week by lysis and leaves no bad effects. 

COMPLICATIONS: Bronchopneumonia is a frequent com- 
plication of measles and when it occurs, disability is prolonged 
and varies according to the severity of the complication and 
strength of the individual. 

G astro-Intestinal Catarrh often follows an attack of measles 
when an adult suffers from this disease of childhood. 

Tuberculosis is one of the frequent complications when 
measles occurs in children, but it rarely follows an attack in 
adults. 

HOUSE CONFINEMENT in individuals who might be 
disabled by this disease seldom begins until the appearance of the 
eruption and does not last more than from 7 to 10 days from this 
time. 

TOTAL DISABILITY in all classes of risks lasts from i to 
2 weeks unless a complication prolongs this time. If disability 
from measles terminates during wet and inclement weather, total 
disability may be increased from 2 to 3 or 5 days. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the poHcy after the termination of house confine- 
ment, is almost never deserved by claimants who have suffered 
from this disease. 

EFFECTS: Adults suffering from an attack of measles are 
insurable for all kinds of insurance from two to four weeks after 
complete recovery takes place. 

RELAPSING FEVER 

SYNONYMS: Famine fever; spirillum fever; febris recur- 
rens; bilious typhoid fever. 

INFORMATION: Relapsing fever is an acute, contagious 
disease occurring in epidemics, more common in hot climates 
than in the temperate zone and is caused by a spiral-shaped mi- 
crobe, the Spirochaeta of Obermeier, which gains access to the 
body through infected foods and liquids. The period of incuba- 
tion is from five to eight days. 

SIGNS AND SYMPTOMS : The onset of an attack of this 
disease is sudden, beginning with a chill, followed by fever which 
reached 102° to 105° F. within twonly-fonr hours from the time 



^^^^ 



488 FEVERS 

the chill occurs, and is accompanied by nausea, vomiting, weak 
pulse, high fever, intense pain in the head, back and joints. These 
signs and symptoms persist for five or six days when the tem- 
perature suddenly falls to normal and other evidence of the dis- 
ease disappears. This period of calm lasts for the same length 
of time as the fever has persisted, when it is followed by a re- 
lapse which produces the same signs and symptoms in a milder 
form and is of shorter duration; at the end of the relapse another 
may take place or a slow convalescence may be established. 

'differential DIAGNOSIS: Remittent Fever may re- 
semble relapsing fever, but in the former there is a sweating stage 
which is not present in relapsing fever, the temperature does not 
reach the maximum height in remittent fever until after four or 




Fig. 113. — Spirochaeta Obermieri from human blood. (Kolle, 
Wassermann and McFarland). 

five days, while in relapsing fever it goes up suddenly and remains 
high until the crisis, — which occurs abruptly. Microscopic ex- 
amination of the blood shows the spirillum in relapsing f^ver and 
the Plasmodium malari^e in remittent fever. 

Yellozu Fever closely resembles relapsing fever in the early 
stages, the temperature reaching a high point in both in the be- 
ginning of the disease. In yellow fever, however, the febrile 
stage is shorter and during the relapse the temperature does not 
quite reach normal; vomiting in yellow fever occurs in the third 
stage, while in relapsing fever it is an early symptom. Yellow 
fever has a characteristic yellow discoloration of the skin and a 
microscopic examination makes the diagnosis clear by showing 
the spirillum in relapsing fever. 



SCARLET FEVER 489 

Typhus Fever occurs under conditions similar to those found 
in relapsing fever, but in the former there is a contracted pupil, 
the expression is dull and apathetic, low muttering delirium is 
present and a spotted eruption which becomes petechial appears. 

COMPLICATIONS involving the eyes, lungs, kidneys, 
spleen, stomach and bowels are frequent in attacks of relapsing 
fever and prolong disability according to the situation and sever- 
ity of the complication. 

HOUSE CONFINEMENT in an average case of this dis- 
ease lasts from 3 to 6 weeks. If a number of relapses have oc- 
curred and much weakness and emaciation is the result, house 
confinement may persist from 6 to 10 weeks. 

TOTAL DISABILITY lasts from 4 to 6 weeks after an or- 
dinary attack of relapsing fever. If a number of relapses have 
occurred and house confinement has been lengthened thereby, 
total disability of from 8 to 10 or 12 weeks may be necessary. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, depends on the character of recovery and the resulting 
weakness and emaciation. If the attack has been mild, from i 
to 2 or 3 weeks of this form of disability are sufficient, but when 
house confinement has been prolonged and accompanied with re- 
lapses and complications, from 4 to 8 or 12 weeks of partial in- 
demnity for total disability may be demanded. 

EFFECTS : When a history of relapsing fever exists in an 
individual, insurance of all kinds must be denied such a person 
until one to two years after complete recovery and a medical ex- 
amination shows the physical condition to be normal. 

SCARLET FEVER 

SYNONYM: Scarlatina. 

INFORMATION: Scarlet fever is an acute, self-limited, 
contagious disease, more common in childhood and often com- 
plicated with an acute inflammation of the middle ear or kidneys. 
One attack usually confers immunity. The disease is caused by a 
poison which has not yet been isolated, but which retains its 
power of producing a recurrence for a long tinie. The period of 
incubation is from a few hours to four or six days. 

SIGNS AND SYMPTOMS: Scarlet fever begins abruptly, 
generally with vomiting or convulsions in young children: in 
those older and in adults, a chill frequently marks the onset. 



490 FEVERS 



1 



There is headache, thirst, coated tongue, constipation, rapid pulse 
and high fever; the latter soon reaching 104° to 105° F., within 
twenty-four to forty-eight hours. At the end of the first day a 
scarlet punctiform rash appears on the neck and chest and rapidly 
spreads over the body. This rash or eruption lasts from five to 
seven days when it gradually disappears and is followed by a des- 
quamation of bran-like scales, the temperature at the same time 
falling by lysis. There is early sore-throat in scarlet fever, often 
nervous symptoms such as insomnia, dehrium and convulsions, 
the urine is high-colored, scantv and often contains albumin. 

DIFFERENTIAL DIAGNOSIS : Diphtheria should not 
cause a mistake in diagnosis, as this disease is not so sudden in 
onset. It is characterized by a false membrane which contains 
the Klebs-Loeffler bacillus and the absence of a rash is apparent. 

Measles is diagnosed by the preponderance of catarrhal symp- 
toms involving the nose, throat and eyes. The rash does not ap- 
pear until the third or fourth day and shows itself by blotches 
which are arranged in a crescentic form and the remission of 
fever on the second or third day. 

Small-Pox is slower in onset and the eruption of this disease, 
which first appears on the forehead and wrists, does not show 
until the third day and soon becomes pustular. There is a decided 
remission in the temperature on the appearance of the rash which 
is not present in scarlet fever and the character of the rash soon 
serves to make a correct diagnosis. 

Dengue is diagnosed from scarlet fever by the severe pain in 
the head, back and joints, with stiffness in the muscles and the 
remission which occurs and lasts from one to two days. The 
rash of dengue is often accompanied by intense itching and gen- 
erally the disease is epidemic. 

• Acute Tonsilitis when accompanied by a rash may resemble 
scarlet fever, but in the former there is no histor}'^ of exposure, 
the characteristic strawberry tongue in scarlet fever is not pres- 
ent, the pulse is less rapid and convalescence is quickly estab- 
lished. 

Accidental Rashes result from certain drugs, such as the bro- 
mides, quinin, belladonna and from the ingestion of foods like ice 
cream, berries, crabs, etc. When these rashes are present there 
is generally a history of a certain article of diet or drug which 
has been taken and produced the rash previously. Fever and 
throat symptoms are absent in rashes thus produced, while they 
are always present in scarlet fever. 



PLATE XV 






Scarlet Fever Eruption on the Third Day (Hoekor. TrunuH\ Abt and 

Mcronibs). 



-nvqspmv 



SCARLET FEVER 491 

COMPLICATIONS: Nephritis is the most common com- 
plication of scarlet fever and develops during convalescence. If 
severe, death may be the result or a chronic inflamxmation of the 
kidneys follow and when this latter occurs, disability is prolonged. 

Otitis Media frequently complicates scarlet fever, but unless 
this causes infection of the mastoid process or brain, disability is 
not lengthened. When the mastoid process is involved and an 
operation required for the cure of this complication, disability 
is greatly prolonged and is described under Injuries and Diseases 
of the Ears. 

Tlie Heart, Lungs and Joints are sometimes affected during 
an attack of scarlet fever. If these parts of the body are involved, 
disability is prolonged according to the kind and severity of the 
complication. 

HOUSE CONFINEMENT in mild cases of scarlet fever 
lasts from 2 to 3 weeks. When the disease is moderately severe, 
from 3 to 5 weeks are necessar}^ and when especially severe at- 
tacks occur and are followed by complications, from 4 to 8 weeks 
and sometimes longer periods are required; this time depending 
on the physical condition of the individual and the number and 
character of the complications. 

TOTAL DISABILITY in adults suffering with a mild at- 
tack of scarlet fever lasts from 2 to 4 weeks. If the attack has 
been severe from 4 to 8 weeks are often necessary. Complica- 
tions involving the kidneys and suppuration of the glands of the 
neck, cause a prolongation of total disability of from i to 2 or 3 
weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy in addition to house confinement, in mild 
cases demands from i to 2 weeks and in severe ones from 3 to 6 
weeks. 

EFFECTS: If a history of a mild attack of scarlet fever ex- 
ists and a complete recovery has followed as indicated by a medi- 
cal examination, insurance of all kinds can be granted from three 
to six months after the termination of the disease. Severe attacks, 
complicated by inflammation of the kidneys, render the individu:ii 
iminsurable for any kind of insurance until six to twelve months 
after complete recovery and frequent examinations of the urine 
show it to be normal. If suppuration of the ear has existed, in- 
surance companies will not issue any form of policy until one to 
three years after complete cessation of the discharge. Sometimes 
accident insurance can be secured by iiulixitluals sutToring with a 



w^mmmsm 



492 FEVERS 

discharge from the ear as the result of scarlet fever or other 
causes., but it is questionable if such a policy can be safely issued 
by any company. 

SIMPLE COXTIXUED FEVER 

SYXOXY]\IS: Irritative fever; ephemeral fever; febricula; 
synocha. 

INFORMATIOX' : Simple continued fever is an acute, mild 
fever of short duration and is usually due to excesses in eating or 
drinking, violent mental or physical fatigue and exposure to heat 
or cold. It is more common in children and young adults of a 
sensitive, nervous temperament. 

SIGXS AXD SYMPTOMS: This form of fever generallv 
begins suddenly with a feeling of malaise, headache, thirst, coated 
tongue, chilliness and elevation of temperature which soon 
reaches a maximum of 102° to 103° F. The bowels are consti- 
pated, while the urine is scanty and high-colored. If the fever is 
caused by errors in diet, nausea and vomiting usually accompany 
the attack and if in children when due to excitement, convulsions 
and shght delirium mav be present. 

DIFFEREXTIAL DIAGXO.SIS: A number of diseases 
may begin and resemble simple continued fever, but the persist- 
ence of the fever, together with the characteristic signs and symp- 
toms pertaining to the disease which are present, wih serve in 
time to make the diagnosis between simple continued fever and 
any other disease that may be existing. 

HOUSE COXFIXE'^IEXT of from 2 to 5 days is usually 
sufficient for attacks of simple continued fever; sometimes, how- 
ever, the fever may be unduly prolonged in sensitive individuals^ 
when from 7 to 10 days may be necessary. 

TOTAL DISABILITY in all classes of risks seldom lasts 
more than from 2 to 5 days and unless a disability policy pays for 
indemnity under one week, no claim exists. Very severe cases 
of this fever sometimes require from i to 2 weeks of total dis 
abilitA'. 

PARTIAL IXDE^IXITY FOR TOTAL DISABILITY i£ 
payable by the policy after the termination of house confinement 
should not be necessary, as the disease is not of long enough 
duration or the temperature high enough to produce sufficient 
weakness to prevent the occupation being resumed as soon as 
house confinement ends. 



TYPHOID FEVER 



493 



EFFECTS: When an attack of simple continued fever has 
been suffered, individuals are insurable for all forms of insurance 
from three to six weeks after complete recovery, 

TYPHOID FEVER 

SYNONYMS: Enteric fever; entero-mesenteric fever; ty- 
phus abdominalis, abdominal typhus; autumnal fever; gastric 
iever; nervous fever. 

INFORMATION: Typhoid fever is an acute, infectious 
•disease due to the bacillus typhosus or bacillus of Eberth, which 
gains access to the system through infected liquids or foods. It 
is more common between the ages of fifteen and thirty years and 




Fig. 114. — Baccillus of Typhoid, with flagella. (H. K. Mulford Co.) 

•occurs more frequently during the late summer and early fall. 
The period of incubation varies from four to twenty-one days. 

SIGNS AND SYMPTOMS: The onset is gradual begin- 
ning with headache which persists and does not yield to treat- 
ment, weakness, vague pains throughout the body, epistaxis and 
a disinclination for work or pleasure. This condition lasts from 
a few days to one to two weeks, when the temperature becomes 
slightly elevated and is accompanied by increased pulse rate. 



mmm 



494 



FEVERS 



coated and tremulous tongue, nausea, hurried breathing, flushed 
face, with distention of the abdomen, enlargement of the spleen 
and the characteristic eruption of rose-colored spots which ap- 
pear from the seventh to the ninth day of the disease, being more 
abundant on the abdomen, chest and back. In the second week 
the above signs and symptoms are exaggerated and this is fol- 
lowed by the third week, during which time the fever begins to 
decline and all symptoms gradually grow less pronounced. A 
relapse may occur at this stage when the temperature again be- 
comes elevated, but not as high as in the early part of the attack. 




Fig. 115. — Rose spots in typhoid fever. The three spots upon the face 
unusual. (Sahli, Kinnicutt and Potter). 



This elevation of temperature persists for a week or ten days 
and is accompanied by the return of the other symptoms, — but in 
a milder form. If a relapse does not follow the receding temper- 
ature, convalescence is estabhshed. Diarrhea or constipation 
may be present. The urine is usually reduced in amount and is 
often albuminous, while much emaciation exists with coma and 
delirium in severe attacks. The Widal test for typhoid fever is 
the reaction shown by the blood when a fresh bouillon-culture of 
the typhoid bacillus is added to it. 

DIFFERENTIAL DIAGNOSIS: Acute Miliarv Tuhercu- 



TYPHOID FEVER 



495 



losis is more often mistaken for typhoid fever than any other (h's- 
ease. In this form of tuberculosis, the temperature curve which 



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is characteristic of typlioid fever is not present, while the curve 
of mihary tuberculosis is more irregular. No rash appears in tu- 



wm< 



496 . FEVERS 



1 

mp-j 
op-| 



berculosis, the A\^idal reaction is absent, while pulmonary symp-j 
toms are more marked and tubercles can be detected by an 
thalmoscopic examination of the retina. 

Meningitis is diagnosed from typhoid fever by the abrupt 
onset with early cerebral symptoms, including photophobia, ver- 
tigo, cerebral vomiting, hyperesthesia and deHrium together with 
irregular fever, leukocytosis and the absence of abdominal S3^mp- 
toms, the characteristic rash and ttfe Widal reaction. 

Ulcerative Endocarditis may be thought to be a beginning at- 
tack of typhoid fever, but the former generally exists as a com- 
plication to some other disease. It is characterized by precordial 
pain and heart murmurs, irregular fever, rigors, leukocytosis and 
the absence of any rash and no reaction when the Widal test is 
applied to the blood. 

Catarrhal Enteritis is sometimes confused with typhoid fever, 
but in enteritis there are colicky pains, nausea, vomiting, and 
when diarrhea supervenes, the stools are greenish-yellow in color 
and contain undigested food. Enteritis sometimes has an erup- 
tion of isolated spots resembling those of typhoid fever and time 
alone must serve to make the diagnosis. This disease, however, 
does not show the Widal reaction, which practically eliminates 
typhoid fever when it is not present. 

COMPLICATIONS : Hemorrhage is one of the most fre- 
quent complications of typhoid fever and generally occurs during 
the third week, being indicated by a sudden fall of temperature 
and the passage of free blood by the rectum or dark red tarry 
stools. It denotes a sloughing ulcer and if not fatal, prolongs the 
period of disability. 

Perforation followed by peritonitis is generally a fatal com- 
plication when it occurs during the course of this fever. It is in- 
dicated by a sudden fall of temperature, localized pain and ten- 
derness with marked tympanites and shock. 

Relapses often occur during an attack of typhoid fever and 
each relapse prolongs disability for at least the length of time 
the relapse requires and usually longer, on account of the severe 
weakness and emaciation which it produces. 

Pneumonia is a frequent complication and when it supervenes 
late in the disease, the period of disability is prolonged thereby, 
provided recovery eventually follows. 

SEQUELAE : Tuberculosis of the Lungs sometimes develops 
in persons predisposed to this disease who have suffered from an 



TYPHOID FEVER 497 

attack of typhoid fever, which is followed by a slow and pro- 
longed convalescence. 

Nephritis or a subacute inflammation of the kidneys may re- 
main as the result of typhoid fever and prolong disability indefi- 
nitely. 

HOUSE CONFINEMENT in aborted cases of this disease 
lasts from i to 2 weeks. Special health policies in which typhoid 
fever is specified as one of the diseases for which indemnity is 
payable, are differently interpreted by the many companies as to 
liability when an individual has suffered from an aborted case of 
typhoid fever as certified by the attending physician; some com- 
panies holding that aborted typhoid fever is not typhoid fever in 
the meaning of the policy. Mild cases of this disease require 
from 4 to 6 weeks of house confinement and in severe ones, when 
there has been one or more relapses, confinement to bed and the 
house may last from lo to 12 or 14 weeks and sometimes even 
longer. 

TOTAL DISABILITY depends on the severity of the dis- 
ease. Aborted cases of typhoid fever usually require from 2 to 3 
weeks of total disability. The average case of this disease de- 
mands from 6 to 8 or 10 weeks. In a moderately severe case in 
which the complications are limited and one relapse only occurs, 
total disability of from 10 to 12 weeks is not uncommon. Very 
severe cases of this fever complicated by one or more complica- 
tions and several relapses require from 12 to 16 weeks or more 
of total disability. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy in addition to house confinement may re- 
quire from I to 2 weeks in mild cases; from 3 to 6 weeks in mod- 
erately severe ones and in very severe cases with a history of 
complications, from 4 to 8 or 12 weeks of this form of disability 
may be necessary. 

EFFECTS: Individuals having suffered from typhoid fever 
in which complications have been absent or slight, are insurable 
for all kinds of insurance from six to nine months after com- 
plete recovery. Severe cases in which total disability has lasted 
from three to six months or more, would not be insurable for life 
or health insurance until one to two years after complete recov- 
ery had taken place. Accident insurance, however, could be 
safely written in the majority of such cases three months after the 
date of recovery. While an individual is recovering from a mild 
attack of typhoid fever, insurance coniixinios ([o not otton cancel 
32 



MM 



498 FEVERS 

a health policy, but permit it to remain in force. If a severe at- 
tack, hoAvever, has been suffered, health insurance is generally 
cancelled and not rewritten until as above stated. When accident 
insurance is in force on any one recovering from an attack of 
typhoid fever, it is seldom disturbed by an insurance company. 

TYPHUS FEVER 

SYNONYMS: Jail fever; ship fever; contagious fever; 
spotted fever; putrid fever; camp fever; exanthematic typhus; 
petechial t3^phus; typhus siderans. 

INFORMATION: Typhus fever is an acute, contagious 
disease occurring in epidemics and supposed to be due to a germ 
which is yet undiscovered. Predisposing causes are the drinking 
of impure water, eating improper foods and breathing foul air in 
overcrowded tenements. It is more common in the continental 




Fig. 117. — Temperature-chart of typhus fever. (Stevens). 

countries and is seldom seen in the United States — except in 
seaports. The period of incubation is four to twelve days, usually 
the latter. 

SIGNS AND SYMPTOMS: The onset of an attack of ty-j 
phus fever is sudden, beginning with a chill and pain in the head, 
back and Hmbs, rapid pulse, fever reaching 104° to 105° F., within 
two to three days and extreme prostration. From the fifth to 
the seventh day of the disease, an eruption resembling measles 
appears over all parts of the body with the exception of the face 
which is of a dusky hue. The urine is scanty and albuminous an 
in some cases nervous s^aiiptoms are prominent. At the end of th 
second week if recovery takes place, the temperature falls b 
crisis and rapid convalescence is established. 

DIFFERENTIAL DIAGNOSIS: Typhoid Fever is differ- 
entiated from typhus fever by the gradual onset of the disease, 
the characteristic temperature curve, the later appearance of the 



\ 



1 



, TYPHUS FEVER 499 

eruption which is scanty and limited to certain parts of the body, 
tympanites and the Widal reaction which is present in the ma- 
jority of typhoid fever cases. 

Cerebrospinal Meningitis is hard to differentiate from typhus 
fever, but in cerebro-spinal meningitis the pain in the back and 
rigidity of the muscles are greater, vomiting is more common, 
the fever is more irregular, prostration less severe and the erup- 
tion appears at different times and is not characteristic. 

Measles is a much milder disease and is marked with catarrhal 
symptoms, while the eruption appears eadier and is confined to 
the face. 

COMPLICATIONS : Pneumonia not infrequently follows 
an attack of t3^phus fever and when this disease supervenes, total 
disability is increased. 

Swelling of the Parotid Glands may follow this fever, but un- 
less suppuration ensues disability is not prolonged thereby. 

HOUSE CONFINEMENT lasts from 3 to 7 days in severe 
cases of typhus fever, at the end of which time a fatal termination 
occurs. The average case ending in recovery requires from 2 to 
4 weeks of house confinement. When complications such as 
pneumonia, suppuration of glands, nephritis or neuritis occurs, 
house confinement is prolonged according to the length of time 
required by the complication for recovery. 

TOTAL DISABILITY in severe cases which terminate by 
death, is seldom over 10 days. Cases in which recovery follow^s, 
require from 3 to 6 weeks of total disability when uncompHcated. 
If complications occur, disability is prolonged according to the 
complication. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable b}^ the policy after the termination of house confine- 
ment, requires from i to 3 weeks in average uncomplicated cases. 
If complications are present, from 2 to 6 weeks of this form of 
disability are necessary. 

EFFECTS: When a history of an attack of typhus fever is 
elicited in an insurance application, all forms of insurance must 
be denied the individual until at least six to nine months have 
elapsed after complete recovery, and even at that time no form 
of life or health insurance should be issued without a favc^rable 
report from a medical examination. 



500 FEVERS 

YELLOW FEVER 

SYNONYMS: Yellow Jack; sailors' fever; Mediterranean 
fever; black vomit; bilious malignant fever; typhus icterode. 

INFORMATION: Yellow fever is an acute, infectious, par- 
oxysmal disease usually occurring in three stages, the febrile, the 
remission and the collapse. It is a disease of the tropics and is 
more common in the seaports and during the summer months 
and is caused by a specific micro-organism which gains access to 
the system through the bites of certain mosquitoes — the Ste- 
gomyiaiasciata. This fever generally occurs in epidemics which 
cease with the beginning of frost. It is more prevalent in the 
white race than in the negro and usually one attack confers im- 
munity against others. The period of incubation is from a few 
hours to seven days, although rarely this time is extended to two 
weeks. 

SIGNS AND SYMPTOMS: The first stage commences 
slowly with headache, loss of appetite and malaise, or suddenly 
with a chill followed by pains in the head, limbs, epigastrium and 
back, with a temperature which rapidly increases until it reaches 
within a few hours 104° to 106° F. This febrile stage lasts from 
one to three or four days and is followed by a rapid fall in tem- 
perature and marked remission of all other signs and symptoms. 
This is the stage of remission in which convalescence may be es- 
tablished or the third stage, the stage of collapse follows in from 
a few hours to two or four days. The stage of collapse is char- 
acterized by persistent vomiting of dark blood, — black vomit, — 
suppression of urine, hemorrhages into the mucous membrane 
and jaundice. The pulse is feeble, skin cold, respiration irregu- 
lar, the mind remaining clear until the end which occurs from ex- 
haustion within a few hours to one or two days. 

DIFFERENTIAL DIAGNOSIS: Dengue is sometimes 
mistaken for yellow fever, but in the former there is intense head- 
ache with severe aching pains in the joints and muscles and often 
a rash. The remission which occurs in dengue is followed by les- 
sening of the symptoms instead of an aggravation as in yellow 
fever, which is characterized by early albuminuria, black vomit 
and jaundice; these being absent in dengue. 

Remittent Fever is diagnosed from yellow fever by the ab- 
sence of black vomit, yellow discoloration of the skin, enlarge- 
ment of the spleen, multiple remissions and the detection by the 
microscope of the hematozoa of Laveran in the blood. 



YELLOW FEVER 501 

Acute Yellow Atrophy of the Liver is distinguished from yellow 
fever by a slight elevation of temperature or the entire absence 
of the fever, marked nervous symptoms, decrease in the area of 
hepatic dullness, and the presence of albumin, bile, tube casts, 
leucin and tyrosin in the urine. 

COMPLICATIONS are rarely seen, although lymphangitis 
and phlebitis may occur as complications and prolong disabihty. 

HOUSE CONFINEMENT depends on the severity of the 
attack and the character of the disease existing in the epidemic 
which is occurring at the time cases are seen. Severe cases cause 
house confinement of from i to 2 or 3 days only when death oc- 
curs. Attacks less severe and those followed by recovery require 
from 3 to 10 days of house confinement. 

TOTAL DISABILITY in early fatal cases is never more 
than from i to 3 days and unless a health or disability policy pays 
indemnity for disability under one week, such cases are not en- 
titled to any indemnity. Individuals who suffer from a moder- 
ately severe attack which is followed by death are totally disabled 
from I to 2 weeks; if recovery takes place total disability lasts 
from 2 to 4 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment requires from i to 2 or 3 weeks; this time depending on the 
physical condition of the person when the attack occurs, the se- 
verity of the disease and the exhaustion which follows. 

EFFECTS: Individuals who recover from attacks of yellow 
fever are not insurable for any kind of insurance until four to 
eight months after complete recovery. 



CHAPTER XX 

MISCELLANEOUS DISEASES 

ASCITES 

SYNONYMS: Hydro-peritoneum; peritoneal dropsy; 
dropsy of the abdomen. 

INFORMATION: Ascites is a collection of fluid in the 
peritoneal cavity. It is due to diseases of the heart, lungs, kidneys, 
liver and pressure within the abdominal cavity. 

SIGNS AND SYMPTOMS: The onset of this condition is 
gradual, beginning with swelling of the abdomen, constipation, 
decreased urinary flow and symptoms referable to the organ 
causing the ascites. On palpation of the abdomen, a wave-like 
impulse is imparted to the hand when tapping is made on the 
opposite side. Percussion shows dullness on the sides of the ab- 
domen; this area of dullness being altered when a changed posi- 
tion is assumed by the individual. A tympanitic note is elicited 
over the intestines which float on the fluid. 

DIFFERENTIAL DIAGNOSIS: Distention of the Bladder 
may be mistaken for general ascites, but in the former there is a 
history of the passage of a srnall amount of urine or absolute re- 
tention, with tenderness and dullness over the bladder. The 
passing of a catheter relieves the condition and shows the correct 
diagnosis. 

Ovarian Tumors are diagnosed from ascites by the fact that 
when a tumor is present the enlargement is at first unilateral and 
is detected by bimanual palpation. If an ovarian tumor exists 
dullness is elicited over the tumor and resonance is found on the 
sides. An altered position does not change the area of dulhiess 
or the situation of the tumor. 

Pregnancy shows a history of the absence of menstruation, 
increase in size of the mammx with a darker areoloe surrounding 
the nipples, the character and position of the enlargement, to- 
gether, at the proper time, with fetal lieart sounds. 

Chronic Peritonitis is marked by a history of chronic intlani- 
mation of the abdomen with general pain, tenderness and vomir- 

503 



504 MISCELLANEOUS DISEASES 

ing and is associated with a chronic disease such as cancer or 
tuberculosis existing in the abdominal cavity or some other part 
of the body. 

COMPLICATIONS: Diseases of the Liver, Lungs, Heart, 
Kidneys or other organs generally complicate ascites, and when 
this condition is claimed as the cause of disability, it is almost 
invariably true that a chronic disease is existing in some part of 
the body and is the primary cause. 

HOUSE CONFINEMENT does not exist in this condition 
unless the collection of fluid in the abdominal cavity becomes so 
large that motion is interfered with, when house confinement is 
necessary until the fluid is removed by aspiration. This time 
should not be more than i to 2 weeks. 

TOTAL DISABILITY of i week should be sufficient in all 
cases of ascites which produce disabiHty from the collection of 
fluid alone, as the majority of persons suffering with this condi- 
tion are also suffering from a disease of some of the other organs 
and the above time is ample for aspiration and the period follow- 
ing before recovery is sufflcient to enable part of the occupation 
being resumed. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is not allowable for this condition alone, but may be neces- 
sary on account of the co-existing disease of some other organ of 
the body and this time depends on the disease and organ in- 
volved. 

EFFECTS: Individuals suffering with ascites are not in- 
surable for any kind of a policy. If a history of such a condition 
has existed previous to the time of appHcation and was appar- 
ently cured, each case would have to be considered separately and 
a decision rendered according to the history eHcited. 



CHOLERA 



.nd j 

4 



SYNONYMS: iVsiatic cholera; malignant cholera; epidemic 
cholera; spasmodic cholera. 

INFORMATION: Cholera is an acute, infectious disease 
usually occurring in epidemics, but more common in the tropics 
than in other parts of the world and is due to a specific micro- 
organism — Koch's comma-bacillus, — which gains access to the 
body through the taking of impure foods and water. Epidemics 
occur more frequently in summer than in winter and all ages are 



CHOLERA 



505 



affected; the old, however, being more susceptible. The period 
of incubation is from three to five days. 

SIGNS AND SYMPTOMS : Typical cases of cholera which 
are followed by recovery, are characterized by three stages — the 
preliminary diarrhea, stage of collapse and stage of reaction. 
Rapidly fatal cases lack the latter stage. The first stage usually 
begins gradually with headache, coated tongue, excessive thirst, 
chilliness, slight pain in the abdomen with diarrhea and weakness, 
but some cases begin suddenly with the above symptoms severely 
marked. The stage of invasion may last from two to five days, 
when convalescence may be established or the second stage or 
collapse follows, in which the thirst becomes more intense, mus- 




Fig-. lis. — Spirillum of Asiatic cholera, from a 
bouillon culture three weeks old, showing long 
spirals. X 1000 (Frankel and Pfeiffer). 



cular cramps occur in the calves of the legs and other parts of 
the body, projectile vomiting is seen and the stools which resem- 
ble rice-water, rapidly increase in number and amount. The skin 
is cold and clammy and covered with perspiration; the surface 
temperature is greatly depressed, but if taken in the rectum it 
may show 102° to 103° F. or more. The urine is extremely 
scanty and contains sugar and albumin. Consciousness is usually 
retained until near the end. This stage lasts from a few hours 
to one or two days when death generally occurs, although in some 
cases convalescence is established at this late period of the dis- 
ease. If the stage of reaction ensues the vomiting ceases, evacua- 
tions from the bowels become less frequent, the pulse increases 



506 MISCELLANEOUS DISEASES 

in strength and the surface temperature becomes normal or nearly 
so. The quantity of urine is increased in amount and the indi- 
vidual begins to take more interest in his surroundings. 

DIFFERENTIAL DIAGNOSIS: Cholera Morbus in the 
beginning stages might be mistaken for cholera in localities 
where this disease was epidemic, but in cholera morbus there is 
usually a history of indiscretion in diet, the prostration is not so 
great and a microscopic examination of the discharges would 
soon eliminate cholera. 

Acute Toxic Gastro-Enfcritis is distinguished from cholera by 
the mildness of the attack, the character of the evacuations from 
the bowels and the absence of cramps in the legs and collapse in 
the early stages. 

COMPLICATIONS : Acute Nephritis generally complicates 
an attack of this disease, but when present total disabihty is not 
prolonged. 

Pneumonia and Pleurisy may occur in the later stages of an 
attack of cholera and if either of these complications are pres- 
ent, disability is lengthened. 

Suppuration of the Parotid Gland not infrequently follows an 
attack of cholera and when it occurs, disability is prolonged 
thereby. 

Ulcers and Abscesses in different parts of the body are not 
uncommon in cases of this disease which have recovered and 
when present, the period of disability is lengthened according to 
the location of the abscess or ulceration, the severity and physical 
condition of the individual. 

HOUSE CONFINEMENT in rapidly fatal cases of cholera 
lasts from i to 2 or 3 days only, but in those which go on to re- 
covery and are uncomplicated, house confinement of i to 2 weeks 
is usually sufficient. Cases in which many complications are pres- 
ent, together with extreme prostration following the disease, are 
confined to the house from 3 to 4 or 6 weeks and sometimes 
longer. 

TOTAL DISABILITY in fatal cases seldom lasts more than 
from 3 to 7 days. If recovery ensues in a case of average dura- 
tion of this disease, total disability of from 3 to 4 weeks is de- 
manded. Severe cases of cholera which are compHcated and fol- 
lowed by much emaciation and weakness, require total disability 
of from 4 to 8 or 10 weeks and sometimes longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 



DIABETES MELLITUS 507 

ment may require from 3 to 6 or lo weeks; this time depending 
on the severity of the attack, the resulting physical condition, the 
occupation and the season of the year. 

EFFECTS : When a history of an attack of cholera is elicited 
in an insurance application, such an individual is uninsurable for 
life or health insurance until one to two years after complete re- 
covery. Accident insurance, however, may be safely written 
from two to three months after recovery is said to have been com- 
plete. 

DIABETES MELLITUS 

SYNONYMS: Glycosuria; melituria. 

INFORMATION: Diabetes mellitus is a chronic disease 
that occurs at all ages, but more frequently between twenty-five 
and fifty years. It is more common in males than in females and 
is especially frequent in the Hebrew race and is rare in negroes. 
The origin of this disease is unknown, although a number of 
theories are advanced as to the probable cause gf it, — among 
which are the disorders of the renal or nervous system, the brain, 
liver and excesses of various kinds. 

SIGNS AND SYMPTOMS : The onset of diabetes mellitus 
is insidious, beginning with the passage of an increased amount 
of urine, normal or subnormal temperature, thirst, loss of flesh 
and strength with increased appetite, headache, etc. As the dis- 
ease advances, there is ''muscular weakness without cause, ema- 
ciation, thirst, hunger, loss of sexual power" (Musser) and ex- 
cessive amounts of urine are voided daily. This fluid is pale in 
color with a specific gravity of 1030 to 1050, of a sweetish taste, 
aromatic odor and containing grape sugar. Great thirst with 
fissures of the tongue and much loss of flesh and strength are 
noticed. Acute exacerbations occur during the progress of this 
disease and cause disability for a short time. 

DIFFERENTIAL DIAGNOSIS: Diabetes Iiisi/^idus is dif- 
ferentiated from diabetes mellitus by the fact that the specific 
gravity of urine in the former ranges from looi to 1007 and sugar 
is absent from the blood and urine. 

Simple Glycosuria may be mistaken for dia1)otos mollitus. but 
in the former sugar in the urine is not constant, only occurring- 
at intervals and most often in those past fifty years of ago. The 
reduction of copper in Fehling's solution takes place when grapo 
sugar is present in the urine of diabetics. 



508 MISCELLANEOUS DISEASES 

Reduction of Fehling's Solution by urine may follow when an 
individual has been under the influence of chloroform or is tak- 
ing chloral. The majority of coal tar products such as phenacetin, 
acetanilid, etc., reduce this solution and sometimes excitement or 
head injuries produce the same results. 

COMPLICATIONS: Brighfs Disease is a frequent compli- 
cation existing in persons suffering with diabetes mellitus. In 
such cases, unless an acute exacerbation of either disease occurs, 
total disability is not often present until near the termination of 
the life of the individual, but when it does follow under such con- 
ditions it usually lasts until a fatal ending occurs. 

Pulmonary Tuberculosis often exists in conjunction with this 
disease and unless the tuberculous process is advanced, it alone 
does not cause disability. 

Boils, Carbuncles, Pruritus and other skin diseases are frequent 
complications present in persons suffering with diabetes. If 
these compHcations occur, they often cause periods of disability 
and lead to the diagnosis of the original disease. 

Atrophy of the Retina, or the formation of a soft cataract not 
uncommonly follows in persons suft'ering with the above disease. 

Diabetic Coma may occur at any time in an individual suffer- 
ing with diabetes; in which case disabiHty is present during the 
progress of the disease and may terminate in death. 

HOUSE CONFINEMENT does not occur when diabetes 
mellitus exists unless an acute exacerbation takes place or coma 
supervenes, when i to 2 weeks are generally suiflcient. If the 
disease is nearing its termination, from 2 to 4 or 6 weeks may be 
necessary. 

TOTAL DISABILITY in all classes of risks lasts from 2 to 
4 weeks, v/hen an acute exacerbation or an attack of diabetic 
coma occurs. In chronic cases where the disease has been exist- 
ing for some time, total disability of from 4 to 12 weeks and 
sometimes more, is often necessary for the period covering the 
last illness of the individual. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the ending of house confinement in 
acute attacks of diabetes mellitus may require from i to 2 weeks. 

EFFECTS : Life or health insurance would be written by 
the majority of insurance companies after several examinations of 
the urine had been made and that excretion found normal in per- 
sons under thirty years of age with a history of diabetes when the 
disease existed during childhood but had been cured for ten or 



ERYSIPELAS 509 

fifteen years. Accident insurance could be issued to young adults 
with a history of diabetes mellitus, provided the disease has been 
cured for three to five years. All forms of insurance would usually 
be denied a person with a history of diabetes mellitus which had 
existed when the individual was between twenty and thirty years 
or over. 

ERYSIPELAS 



SYNONYMS: St. Anthony's fire; erysipelatous dermatitis; 
the rose. 

INFORMATION: Erysipelas is an acute infectious disease 
caused by the Streptococcus Pyogenes. This disease manifests it- 
self by a localized inflammation of the skin and systemic symp- 
toms. It is more common in those whose physical condition is 
poor and one attack predisposes to another. The face and neck 
are the parts most often involved. The period of incubation is 
from three to seven days. 

SIGNS AND SYMPTOMS may come on gradually with 
chilliness, slight fever, tingling in the parts about to be affected 
and enlargement of the glands adjacent to the localized inflam- 
mation. Usually, however, an attack of erysipelas begins sud- 
denly with a chill, followed by increased temperature which soon 
reaches 103° to 105° F., rapid pulse, pain in the head and limbs, 
sometimes nausea, vomiting and the eruption which most fre- 
quently begins around the nose and spreads to other parts of the 
face, these parts becoming swollen, tense, glazed and of a crim- 
son hue. Small vesicles sometimes develop and these may co- 
alesce forming blisters of a large size. The eruption is accom- 
panied by pain in the parts affected, with tingling and heat. This 
condition persists for four or five days, when the redness and 
swelling begin to subside, desquamation follows, the pain becomes 
lessened, the temperature falls by crisis and convalescence is es- 
tablished in the majority of cases. Relapses, however, are fre- 
quent in this disease and may occur at this stage. 

DIFFERENTIAL DIAGNOSIS is not difficult in this dis- 
ease, as there is frequently a history of exposure to infection, the 
eruption appears early and most often aft'ects the face and sur- 
rounding parts and is accompanied with burning, tingling and 
high fever with scanty and albuminous urine. An important 
point in the diagnosis of erysipelas is the alnnipt termination of 



I 



510 



MISCELLANEOUS DISEASES 



the swelling; this is marked by a ridge at the margin of the in- 
flammation and is easily distinguished by palpation. 

Herpes Zoster of the face and forehead may be mistaken for 
erysipelas, but in the former the eruption is limited by the median 
line, the vesicles appear with the neuralgic pain and the red ede- 
matous appearance follows the vesicles, while in er3^sipelas the 
eruption is not limited by the median line, the pain is not neu- 




Fig. 119. — Swelling- of the face in erysipelas. (Eisendrath). 

ralgic in character and the vesicles follow the redness and swell- 
ing. 

COMPLICATIONS are not frequent following an attack of 
erysipelas, although meningitis, pneumonia and pleurisy may oc- 
cur. If the inflammation involves the neck, edematous laryngitis 
may result. Thrombosis aiTecting the capillaries of the brain 
sometimes complicates or follows an attack of this disease. This 
is also true of the sinuses within the skull. 

HOUSE CONFINEMENT in an average case of erysipelas 
in all classes of risks lasts from i to 2 weeks. \''erv severe attacks 



I 



GOUT 511 

of this disease may cause house confinement of from 2 to 3 weeks 
and in either case, this time may be increased from 2 to 5 days 
when the attack occurs in winter and house confinement termi- 
nates during inclement weather. 

TOTAL DISABILITY generally lasts from 2 to 3 weeks, 
although severe attacks require from 3 to 4 weeks before the oc- 
cupation can be resumed. Complications. would prolong disabil- 
ity according to the time required for the complication. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the ending of house confinement 
may require from i to 2 or 3 weeks; this time depending on the 
physical condition of the individual, the occupation and the sever- 
ity of the disease. Usually, however, as soon as house confine- 
ment ends the occupation can be resumed. 

EFFECTS : Uncomplicated cases of erysipelas produce no 
untoward effects. Therefore insurance of all kinds can be issued 
from two to four months after complete recovery. Good under- 
writing, however, would demand that a waiver be placed on a 
health pohcy eliminating indemnity for this disease, — if the ap- 
plication was accepted within two to three years following an 
attack. 

GOUT 

SYNONYMS: Podagra, — gout in the foot; — gonagra, — 
gout in the knee; — chiragra, — gout in the hand. 

INFORMATION: Gout is a general disease involving dif- 
ferent joints of the body; those of the foot and especially the ones 
in connection with the great toe being most often affected. The 
disease is usually inherited and is more common in middle and 
advanced life, and in the male sex who have indulged in the ex- 
cessive use of wines and malt liquors or overeating of rich articles 
of diet. 

SIGNS AND SYMPTOMS: The paroxysm of an acute at- 
tack of gout is usually preceded several days by prodromes such 
as restlessness, irritability of temper, insomnia, dyspepsia and the 
discharge of scanty high-colored urine. The paroxysm itself be- 
gins suddenly, shortly after midnight and is characterized by 
great pain in the affected joint, this is soon followed by redness, 
heat, swelling and extreme sensitiveness. As daylight ap- 
proaches, the pain becomes less acute and the individual usually 
falls asleep. During the following day the pain in the joint in- 



KSf-^^^^ 



512 MISCELLANEOUS DISEASES 

volved is more or less severe and as night returns another par- 
oxysm ensues, although of lessened severity. This routine per- 
sists for four or five days when convalescence is established. Dur- 
ing the above described attack, the temperature is moderately 
elevated, running from ioi° to 102° F., the pulse is quickened 
and corresponds to the temperature. 

DIFFERENTIAL DIAGNOSIS: Acute Articular Rheuma- 
tism is sometimes mistaken for an attack of gout, but in the 
former the disease generally affects the larger joints of the body, 
the duration is longer and there is a marked tendency to the suc- 
cessive inv^olvement of the larger joints. Acid sweats are com- 
mon in rheumatism and prostration is more severe. 

Rheumatoid Arthritis is not easily differentiated from gout. 
This disease, however, more often affects the joints of the fingers 
and is more common in females than in males. It is a disease of 
long standing which produces a gradual enlargement of the parts 
involved, accompanied by pain and rigidity. 

COMPLICATIONS are often seen in connection with gout; 
this being due to the fact that the disease is more common in 
persons of middle and advanced age and in those who have lived 
a more or less fast life which has had its effects on the various 
organs of the body. Among the most frequent complications 
are hypertrophy of the heart, arterio-sclerosis, nephritis and 
sometimes chronic diseases of the skin. 

HOUSE CONFINEMENT in an acute attack of gout 
usually lasts from 3 to 7 or 10 days. When it occurs in persons 
who are well advanced in life and a number of previous attacks 
have been suffered, house confinement of i to 2 weeks may en- 
sue. 

TOTAL DISABILITY in the average case which has not 
been preceded by a number of previous attacks lasts about i 
week. Severe ones which have a history of recurrences in indi- 
viduals advanced in age, require total disability of from i 1 o 2 or 
even 3 weeks. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment may demand from 3 to 5 or 7 days in the average case. 
V.^hen following very severe attacks, from i to 2 weeks of this 
form of disability — if payable — ^may be necessary. 

EFFECTS : If a history of one or more attacks is elicited 
in an individual well advanced in life, insurance of all kinds must 
be denied such a person. When only one attack has occurred 



HYDROPHOBIA 513 

and all other things are equal, life insurance can be safely written 
if a medical examination proves the individual an average risk. 
Accident and health insurance can also be issued to such a per- 
son, but an insurance company would place a waiver on a health 
poHcy eliminating indemnity for disability following an attack of 
gout if the history of such an attack is elicited as occurring within 
one to three years previous to the date of application. 

HYDROPHOBIA 

SYNONYM: Rabies. 

INFORMATION : Rabies is an acute specific infectious 
disease involving the central nervous system, occurring in certain 
animals and transferred to the human race by bites, when it be- 
comes known under the name of hydrophobia. The bite fromi 
an animal suffering with this disease produces hydrophobia in 
the person bitten, the poison being found in the saliva, blood and 
fluid of the spinal cord of the rabid animal. 

SIGNS AND SYMPTOMS: When hydrophobia follows the 
bite of a rabid dog or other animal similarly affected, it usually 
develops in from three weeks to three months after the wound 
has been inflicted, first showing itself by a restlessness, depres- 
sion of spirits, slight difficulty in swallowing and pain in the un- 
healed wound or scar, with sHght fever and increased pulse rate. 
This condition lasts for a few days, when clonic spasms involving 
the muscles of the larynx supervene and are caused by the sight 
of water or the drinking of it. After one to three or four days, — 
during which time there is moderate fever with an excessive dis- 
charge of saliva from the mouth and delirium, — the convulsions 
cease, the individual lying motionless in a semi-conscious condi- 
tion. This stage persists for twelve to thirty-six hours and ter- 
minates in death in almost everv case. 

DIFFERENTIAL DIAGNOSIS: Hysteria, with a history 
of a bite from an animal must be differentiated from a true attack 
of hydrophobia. Hysteria almost invariably occurs in women 
and in attacks which simulate hydrophobia there are attempts at 
biting, the woman usually barks, but clonic spasms involving the 
muscles of the throat are not induced by swallowing or the siglit 
of water. 

HOUSE CONFINEMENT lasts from 3 to 10 days: the dis- 
ease almost invariably terminating fatally. 

TOTAL DISABILITY is o-enerallv the lenoth of house 



514 MISCELLANEOUS DISEASES 

confinement, although it may be preceded by from i to 3 or 5 
days of this form; in \yhich case from 3 to 10 or 14 days of total 
disability may be necessary. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy in addition to house confinement seldom 
follows an attack of this disease. Should recovery take place, 
however, this form of indemnity would require a variable time, 
from I to 2 or 4 months. 

EFFECTS : If a history of an animal bite is elicited and es- 
pecially if the animal is thought to have suflfered from rabies, such 
a person would be uninsurable for any kind of a policy until one 
to two years had passed after the bite was inflicted, unless the 
Pasteur method of treatment had been taken. In the latter case, 
all kinds of insurance may be safely written from one to three 
months after the treatment was ended. 

PAROTIDITIS 

SYNONYMS: Mumps; parotitis. 

INFORMATION: Parotiditis is an acute, contagious dis- 
ease affecting one or both of the parotid and salivary glands. It 
is due to a specific poison and is more commonly seen in male 
children than in females, although adults are not immune. One 
attack usually confers immunity. Incubation varies from one to 
three weeks. 

SIGNS AND SYMPTOMS: An attack of this disease be- 
gins with chilliness, moderate fever running from 101° to 103** 
F., quickened pulse, headache and stiffness at the angles of the 
jaw, followed by swelling of the parotid gland. As the swelling 
increases and involves the side of the face, pain appears and be- 
comes more marked on movement of the jaws. This condition 
lasts for a few days when the gland of the opposite side generall}'" 
becomes involved and the same routine is repeated. Sometimes 
metastasis occurs and swelling of the mammae or testes results; in 
which case disability is prolonged. 

COMPLICATIONS: Orchitis is the most frequent compli- 
cation and when it occurs it is almost invariably seen in adults; 
thus prolonging the period of disability one to two weeks. 

Other complications such as suppuration of the gland, im- 
pairment of hearing and pneumonia sometimes follow. 

HOUSE CONFINEMENT in individuals suffering with 
this disease lasts from 5 to 7 days, when one gland only is in- 



PERITONITIS 515 

volved. If the gland of the opposite side becomes affected several 
days after the first, house confinement of from 7 to lo days is 
necessary. If orchitis develops, house confinement is prolonged 
from I to 2 and sometimes 3 weeks; this latter time depending 
on the severity of the infection of the testes. 

TOTAL DISABILITY in the average case of mumps af- 
fecting one side of the face only, seldom lasts more than 7 days. 
When the glands of both sides are involved, total disability of 
from 10 to 14 days may be required. If metastasis follows and 
swelling of the testes occurs, total disability of from 2 to 4 weeks 
is sometimes necessary in such cases. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, is not often required in this disease, but if so, from 4 to 7 
days are usually ample. 

EFFECTS: When an adult has suffered from an uncom- 
plicated attack of mumps involving either of the parotid glands, 
insurance of all kinds can be issued from two to four weeks after 
complete recovery. If metastasis has occurred and a complete 
recovery ensues, the risk is desirable for all kinds of insurance, 
but if atrophy of one or both testes follows, such a condition 
would at least require a medical examination before any kind of 
a policy was issued. 

PERITONITIS 

SYNONYM : Inflammation of the peritoneum. 

INFORMATION: Acute peritonitis is an acute inflamma- 
tion of the peritoneum resulting from infection caused by pene- 
trating wounds of the abdomen or perforating wounds of some 
of the organs of the peritoneal cavity, the extension of an exist- 
ing inflammation involving one or more organs of the abdominal 
cavity and general infections, such as tuberculosis, septicemia, 
erysipelas, etc. Exposure is sometimes said to be the cause of an 
acute peritonitis. 

SIGNS AND SYMPTOMS in the acute variety appear sud- 
denly beginning with a chill, elevation of temperature from 101° 
to 103° F., increased pulse rate, shallow breathing with abdominal 
tenderness and localized pain which soon becomes very intense 
and general. The individual voluntarily lies on the back with 
the legs drawn up, thereby relaxing the abdominal nuiscles as 
much as possible; thus attempting to relieve the severe pain 



516 MISCELLANEOUS DISEASES 

which exists. The abdomen is distended and its contents are pro- 
tected by rigid abdominal walls, tympanites is present, constipa- 
tion exists and vomiting usually occurs. A subnormal tempera- 
ture is often seen in this disease. 

DIFFERENTIAL DIAGNOSIS: RJiewnatism of the Ab- 
dominal Muscles may simulate peritonitis, but in the former the 
history of a disease or accident that might result in peritonitis is 
absent, the temperature is not so high, neither is the pulse as 
rapid and symptoms of collapse do not follow. 

Acute Enteritis rarely produces rigidity of the abdominal 
walls; the tenderness is less marked than in peritonitis, the pain 
is colicky in character and diarrhea is present, while in peritonitis 
constipation usually exists. 

Acute Gastritis due to a corrosive poison generally has a 
history of the ingestion of such a drug. The severe pain which is 
present is limited to the stomach and upper part of the abdominal 
cavity, the vomiting is early and severe and collapse supervenes 
in fatal cases very quickly. 

Intestinal Obstruction is characterized by absolute constipa- 
tion, not even wind being expelled per rectum. The fever is not 
as high and tenderness is less intense, while the vomiting which 
first consists of the contents of the stomach soon becomes sterco- 
raceous. 

Biliary Colic is differentiated from peritonitis by the fact that 
in the former the pain is excruciating, is paroxysmal in character 
and when relief ensues it comes instantly. Jaundice of more or 
less intensit}^ is also present. 

Renal Colic should rarel}' be confused with peritonitis. In 
this form of colic the pain is situated over the region of the kid- 
neys and is referred in the male to one of the testes which be- 
comes retracted; in addition the urinary secretion is altered, often- 
times containing blood and albumin. 

Hysterical Distention of the Abdomen is generally seen in the 
female sex, when the abdomen is swollen and the pain and tender- 
ness which are claimed as present, disappear if the attention of 
the patient is distracted. Fever rarely occurs when this condition 
is met with and the pulse is not characteristic of peritonitis. A 
few whififs of chloroform quickly relieves the abdominal disten- 
tion when due to hysteria. 

HOUSE CONFINEMENT is extremely uncertain when 
peritonitis exists and depends on the cause and treatment. Cases 
suffering with a general diffuse peritonitis resulting from a punc- 



ACUTE ARTICULAR RHEUMATISM 517 

tured wound of the abdominal wall or rupture of some of the 
abdominal organs, seldom live longer than from 2 to 7 days. Peri- 
tonitis which becomes more or less diffuse but which yields to 
treatment, may require house confinement of from 2 to 3 or 4 
weeks. When peritonitis is due to an injury and is followed by 
an operation and recovery, from 4 to 6 or 8 weeks of house con- 
finement are necessary. 

TOTAL DISABILITY in cases which terminate fatally sel- 
dom require more than i week. If recovery follows without an 
operation having been performed, from 2 to 4 or 5 weeks are 
usually necessary. When this condition requires an operation 
and recovery ensues, total disability lasts from 4 to 6 or 10 weeks 
and sometimes longer. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy in addition to house confinement usually 
demands from i to 2 or 4 weeks; this time depending on the cause 
of the disease, the severity, the treatment and the physical condi- 
tion of the individual. 

EFFECTS : If a history of peritonitis exists and is the result 
of an accident or rupture of some of the abdominal organs due 
to an acute disease or injury, life or health insurance would not 
be issued until six to twelve months after complete recovery had 
ensued, and not even then unless a medical examination showed 
the individual to be suffering from no untoward effects. Accident 
insurance can generally be accepted on a person with such a his- 
tory from three to six months after recovery is said to be com- 
plete. If tuberculosis or a malignant growth has caused the peri- 
tonitis, such an individual would not be accepted for any kind of 
insurance. 

ACUTE ARTICULAR RHEUMATISM 

SYNONYMS: Inflammatory rheumatism; rheumatic fever; 
rheumatism. 

INFORMATION: Acute articular rheumatism is a disease 
usually affecting the large joints of the body. It is more fre- 
quently seen in occupations requiring exposure and is more com- 
mon in the temperate zone and in early life; the majoritv of cases 
occurring between the ages of fifteen and forty years. The exact 
cause of this disease is not known, but the predispc\<ing causes 
are exposure to cold and wet. One attack renders the individual 
more prone to subsequent ones. 



518 MISCELLANEOUS DISEASES 

SIGNS AND SY:\IPT0:^IS vary in their severity. The dis- 
ease generally manifests itself with chilliness or a chill, sore- 
throat, pain, stiffness and swelling in the joints about to be af- 
fected, thirst, nausea, vomiting and elevation of the temperature, 
this soon reaching 102° to 103° F., and scanty, high-colored, acid 
urine which is albuminous. As the disease advances, the joints 
become greatly enlarged, swollen, reddened, hot to the touch 
and exquisitely tender, the slightest touch or movement causing 
excruciating pain. Profuse acid sweats are present during these 
attacks, later swelling, pain and tenderness subside in the joints 
involved and other joints become swollen and painful. If both 
ankles have been affected early, the disease may affect both knees 
or both shoulders, or if one knee and one ankle were early in- 
volved the inflamm.ation may disappear in these joints and the 
opposite ankle and knee become affected. 

DIFFERENTIAL DIAGNOSIS between rheumatism 
when it is affecting one joint only and a sprain or contusion is not 
difficult, although a rheumatic joint may have a history of injury 
a short time previously. In acute articular rheumatism the en- 
largement of the joint is uniform and completely encircles it, 
while in a contusion the swelling is confined mostly to the exact 
point injured. Tenderness is exquisite at all places in a rheu- 
matic joint while with a contusion the tenderness is greatest over 
the torn ligaments. Fluid is found in some of the larger joints 
in contusions, while in rheumatism it is usually absent. Discolor- 
ation appears after contusions and not after rheumatism, while 
complications involving the heart are frequent in conjunction 
with this disease, but never follow sprains or contusions. 

Acute Rlieuinafoid Arthritis is best differentiated from acute 
articular rheumatism by its course and after effects. It usually 
affects the small joints, leaving permanent impairment and de- 
formity and is not accompanied with acid sweats or lesions of the 
heart. 

Gonorrheal Rh.eiimatism shows a history of gonorrhea and 
generally involves one joint onty, usually the knee. It is of longer 
duration than acute articular rheumatism, does not yield to 
salicylates and if a culture is secured, gonoccocci are found to be 
present in the synovial fluid. 

Septic Artliritis usually involves one joint at a time and later 
is followed by suppuration; this latter almost never occurring in 
acute articular rheumatism. Septic arthritis is generally the 



ACUTE ARTICULAR RHEUMATISM 519 

complication of a septic process in some other part of the body 
and is accompanied by a hectic temperature. 

Acute Periostitis simulates rheumatism when this condition 
occurs in close proximity to a joint, but in the former the swell- 
ing is less intense and the tenderness and heat when accurately 
located are not found to be in the joint. Fluctuation over a cir- 
cumscribed area shows the presence of pus in periostitis and this 
does not occur in rheumatism. 

Gout should not be mistaken for acute articular rheumatism. 
In the former the joints of the great toe are most frequently at- 
tacked and the disease first shows itself in the early morning 
hours. High fever and acid sweats with a tendency to heart com- 
plications are absent. 

COMPLICATIONS: Endocarditis, Pericarditis and Myocar- 
ditis are the most frequent complications of this disease and when 
they occur, disability is greatly prolonged in cases in which re- 
covery ensues. 

Pneumonia, Bronchitis and Pleurisy are complications of this 
disease, occurring in ten to fifteen per cent of cases. 

HOUSE CONFINEMENT in the average uncomplicated 
case of acute articular rheumatism lasts from 2 to 4 weeks. If a 
complication involving the heart occurs or the lungs become af- 
fected, house confinement is increased according to the length ui 
time required for the complication and sometimes even longer, 
on account of the individual being in poor physical condition 
when complications ensue. 

TOTAL DISABILITY in preferred risks whose occupation 
does not necessitate exposure, lasts from 3 to 6 weeks in the aver- 
age uncomplicated case. In other lower classifications in which 
more or less exposure is necessary in the occupation, total dis- 
ability of from 4 to 8 weeks is often required. If a complication 
involving the heart or lungs or other organs of the body occurs, 
this form of disability is prolonged according to the time required 
for the complication and on account of the pre-existing disease, 
from I to 2 or 3 weeks more are usuallv demanded. 

PARTIAL INDEMNITY FOR' TOTAL DISABILITY 
if payable by the policy in addition to house confinement, gener- 
ally requires from 2 to 4 weeks; this time depending on the se- 
verity of the attack, the number and situation of the joints in- 
volved, the severity of the complications — if any — and the exact 
duties of the occupation. 

EFFECTS: An individual having one or nu^ro attacks of 



520 MISCELLANEOUS DISEASES 

acute articular rheumatism is uninsurable for a life policy until 
three to six months or more have elapsed after the termination 
of the last attack and a medical examination shows the heart and 
other organs to have been unimpaired by the disease. Health 
insurance in such cases can be issued from three to six months 
after the termination of the last attack and the medical exami- 
nation shows the heart to be normal, but good underwriting 
would demand that a waiver be placed on the policy eliminating 
indemnity for this disease. Accident insurance is commonly 
written as soon as recovery takes place, but an accident policy 
should not be issued unless a medical examination has been made 
and the heart found to be normal. 

MUSCULAR RHEUMATISM 

SYNONYMS: According to the location; cephalodynia, 
torticolHs or wry-neck; pleurodynia, lumbago or lumbodynia. 

INFORMATION : Muscular rheumatism is an inflamma- 
tory condition of the voluntary muscles of the body and is known 
by the above names, according to the location of the muscles 
involved. It is more commonly seen in the male sex in advanced 
adult life and most frequently affects the lumbar muscles; often 
being due to exposure to dampness or direct draught of cold air. 
One attack predisposes to others and individuals who are subject 
to gout more frequently sufler with this disease. 

SIGNS AND SYMPTOMS : An attack of muscular rheu- 
matism is often sudden in onset, frequently occurring while the 
individual is bending over and as an attempt is made to resume 
the upright position, intense pain is felt in the lumbar region. 
Stiffness follows in the affected muscles, with tenderness and 
agonizing pain on the slightest movement. Sometimes the mus- 
cles are contracted and rigid, when pain is constant; usually, how- 
ever, if the affected muscles are kept at absolute rest, pain is 
slight or absent. When the occipito-frontal muscles are involved, 
the muscles of the eye may be affected; in which case movement 
of the eyeball causes increased pain. If the muscles of mastica- 
tion are affected, the act of chewing makes the pain more intense. 
When the thoracic muscles are involved, deep breathing, cough- 
ing or sneezing aggravates the pain. 

DIFFERENTIAL DIAGNOSIS: Sprain of the back is 
often claimed as the cause of disability when in reality it is due to 
lumbago. The differential diagnosis, therefore, between these 



MUSCULAR RHEUMATISM 521 

two conditions is very important to an insurance company. If an 
individual is disabled by muscular rheumatism and carries an ac- 
cident policy only, he of course is not entitled to indemnity, while 
if a general health or disability policy is carried and disability is 
due to lumbago, the poHcy may provide a limited sum for such 
disability. When a sprain of the back is the cause of disability, 
a distinct history of injury is obtainable, the disability begins 
slowly and gradually becomes worse so that within twenty-four 
to thirty-six hours it is well marked. Discoloration may or may 
not be present, pain is referred to a special point over the spinal 
column or the muscles of the back and tenderness exists at these 
points when pressure is made over them. There is no elevation 
of temperature and no complications such as would indicate a 
rheumatic condition being present. 

Lumbago in contra-distinction may be present on one side 
only, it comes on suddenly with no history of an accident or 
strain. Tenderness and pain extend over a larger area, no dis- 
coloration follows, the temperature is elevated and frequently 
other manifestations of rheumatism are present in some other 
part of the body. 

Cephalodynia must be differentiated from neuralgia of the 
trifacial or occipital nerves. In the latter disease there is pain and 
tenderness at the points where these nerves emerge from the 
skuH and also following their course. The muscles of the head 
are not involved in neuralgia and movement does not aggravate 
the condition. 

Pleurodynia may be mistaken for pleurisy or intercostal neu- 
ralgia. In pleurisy, evidence of this disease is apparent on per- 
cussion and auscultation, while in intercostal neuralgia the pain 
follows the course of an intercostal nerve and external evidence 
is often seen in an attack of herpes. 

Progressive Muscular Atrophy should not be diagnosed as mus- 
cular rheumatism, because in this disease the history of a gradual 
onset lasting for weeks or months is present. Fibrillary contrac- 
tions is an early symptom and wasting of the nuiscles witli loss of 
power, pallor, coldness and impairment of sensation are present, 
and these symptoms are not seen in muscular rheumatism. 

HOUSE CONFINEMENT in cases of nuisonlar rheuma- 
tism involving the muscles of the chest or back usually lasts from 
3 to 7 days in preferred risks and from i to 2 weeks in ordinary 
ones Severe cases of this form of rheumatism affootino- tlio Uur.- 
bar muscles sometimes cause house confmomont oi from j to ^ 



S22 MISCELLANEOUS DISEASES 

weeks and this is especially the case when attacks closely suc- 
ceed one another. 

TOTAL DISABILITY of i to 2 weeks is most often de- 
manded in attacks of muscular rheumatism. Cases with a history 
of very severe attacks of this disease require from 2 to 4 wee^ks 
of this form of disability. When recovery from this disease takes 
place during- inclement weather, the length of total disability is 
prolonged from 3 to 5 days. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment, does not often require more than i to 2 weeks. 

EFFECTS: Individuals with a history of having suffered 
attacks of muscular rheumatism involving any of the muscles of 
the body, are uninsurable for health insurance, unless a waiver 
is placed on the policy eliminating indemnity for this disease. Ac- 
cident or life insurance, however, can usually be safely written 
from one to two months after complete recovery takes place. On 
account of a wrong diagnosis in many cases of muscular rheuma- 
tism, insurance companies frequently pay indemnity under ac- 
cident policies for this disease, when it is claimed by the attending 
physician that a sprain of the back caused the disability. It is 
therefore necessary that not only a competent physician, but one 
who is constantly on the alert for such a condition, be employed 
when a claimant alleges a sprain of the back as the cause of dis- 
ability. 

SMALLPOX 

SYNONYM: Variola. 

INFORMATION: Smallpox is an acute contagious dis- 
ease usually occurring in epidemics, although sporadic cases may 
be prevalent at all times. It is supposed to be due to a germ, but 
as yet no one has succeeded in isolating the cause. The poison 
is extremely tenacious and may produce an attack after remaining 
in articles of apparel for a long time. Practically every one is 
susceptible to the disease unless protected by vaccination or a 
previous attack which usually confers immunity, but not always. 
The period of incubation is from ten to fourteen days. 

SIGNS AND SYMPTOMS : Smallpox first manifests itself 
by a sudden chill or chilliness, accompanied by vomiting, in- 
creased temperature which soon reaches 103° to 104° F., rapid, 

f 



SMALLPOX 



52J 



full and strong pulse, ranging from lOO to 130 beats per minute, 
redness of the face with injection of the conjunctiva, sleepless- 
ness, constipation, headache, sometimes convulsions and delirium 
and severe pains in the back which are almost never absent. This 
condition continues until the third day of the disease when a char- 
acteristic eruption first appears on the forehead at the line of the 
hair and on the wrists, consisting of coarse red spots, which feel 




Fig. 120. — Discrete small-pox in an iinvac- 
cinated girl. Eighth day of eruption. (Welch 
and Schamberg). 



like small particles of shot beneath the skin; about this time the 
fever abates and the patient is more comfortable and contented. 
These spots pass through successive stages and become p:\pules. 
vesicles and pustules and finally break and discharge and in time 
are covered by a crust or scab, which begins to drop off from 
the seventeenth to the twenty-first day, leaving a red depressed 
surface which in time becomes a while cicatrix. Convalescence 



( 



524 MISCELLANEOUS DISEASES 

is then established and is completed as soon as all scabs or crusts 
become separated from the body. 

Confluent Smallpox is marked by the coalescing of the pus- 
tules and extreme gravity of all other signs and symptoms. 

Malignant, hemorrhagic or black smallpox is characterized 
by hemorrhage into the pustules and is rapidly fatal. 

Varioloid or modified smallpox is shorter and milder than 
the ordinar}^ disease and is not attended with the secondary fever. 

DIFFERENTIAL DIAGNOSIS : Varicella should not be 
mistaken for smallpox, as this disease is almost entirely confined 
to children; constitutional symptoms are mild, the rash appears 
on the first day, becoming vesicular within a few hours and does 
not go on to pustulation and disappears within three to five days. 
In suspicious cases the presence of a vaccination mark would 
serve to make the diagnosis almost positive. 

Syphilis in the pustular form during the second stage, is 
sometimes mistaken for smallpox by experts; the two resembling 
each other so closely in some cases. In the former, however, 
there is usually a history of infection, mucous patches are present 
and the fever is slight. Such cases are sometimes only diagnosed 
by the course of the disease. 

Measles may be mistaken for smallpox, but in the former the 
eruption is smooth, and crescentic in shape, the temperature does 
not fall on its appearance as it does when the eruption of smallpox 
takes place. In measles marked coryza and cough are present, 
while absent in smallpox. 

Typhus Fever is characterized by sudden onset with a marked 
chill and high temperature, and the latter is not affected by the 
appearance of the eruption on the fourth or fifth day as it is in 
smallpox. The eruption in typhus fever is macular and petechial^ 
while in smallpox it is pustular and later umbilicated. 

COMPLICATIONS involving the eyes, lungs or throat are 
frequent, but seldom prolong disability unless occurring near the 
termination of the disease, when the length of disability is in- 
creased according to the time usually demanded by the compli- 
cation. 

HOUSE CONFINEMENT lasts from 3 to 4 weeks in mild 
cases of this disease. If the attack is severe, from 4 to 6 weeks 
and sometimes longer are necessary and this is especially true 
if some of the complications develop towards the ending of the 
disease, when disability is generally prolonged for the length of 
time required for recovery by the complication. 



SMALLPOX 525 

TOTAL DISABILITY in malignant cases seldom lasts 
more than from 5 to 10 days when death takes place. Mild cases 
require from 4 to 6 weeks and when the infection has been severe 
from 6 to 10 or 12 weeks are often necessary. Complications 
such as ulcerative keratitis, ulcerative laryngitis, pneumonia and 
pleurisy prolong the period of disability according to the com- 
plication. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the pohcy after the termination of house confine- 
ment, in the majority of cases does not demand more than from 
I to 3 weeks; this time depending on the severity of the attack. 

EFFECTS : Insurance of all kinds can be issued to indi- 
viduals with a history of having suffered an attack of smallpox, 
from four to six months after complete recovery ensues. 



CHAPTER XXI 

DISABILITY DUE TO POISONS AND GASES 
PART I 

MINERAL POISONS 

Poisoning from mineral or vegetable acids, other vegetable 
poisons, alkalies and gases not uncommonly occurs and results 
either in disabihty or death. Corrosive acids and alkalies when 
taken in concentrated form are followed immediately by signs 
and symptoms referable to the poison taken, and in such cases 
death usually occurs quickly. When these acids or alkalies are 
taken into the system in a diluted form, evidence of the poison 
may not show until some hours afterwards and generally only 
disabihty follows, but in some cases if enough of the diluted 
poison is taken death results. 

Vegetable poisons are often swallowed in overdoses and pro- 
duce toxic effects. This happens most frequently when the drug 
is taken intentionally and does not often occur accidentally. 
Some of these poisons act very quickly and are followed at once 
by the usual evidence of the poison having been swallowed. In 
other cases where the action is delayed on account of the non- 
absorption or dilution of the drug, signs and symptoms may not 
ensue until some hours after the poison has been taken in a toxic 
dose. 

Alkalies when swallowed in the concentrated form are almost 
invariably followed at once by evidence of the poison, although 
as with diluted mineral and vegetable acids, diluted alkalies may 
not produce any untoward symptoms at once, but nevertheless 
if taken in sufficient quantity, poisoning results. 

Gases are either inhaled intentionally or by accident and in 
either case if breathed sufficiently long and undihited by air. 
death almost invariably occurs and usually within a very short 
time. Some gases which produce death are odorless, while 
others are readily distinguished by the smell. Disability or doarh 
often results from the inhalation of fumes from acids or alk:ilios 

527 



528 MINERAL POISONS 

and usually these fumes are inhaled by accident. Poisoning not 
uncommonly follows from constant exposure to certain drugs 
which are inhaled or absorbed by the skin or mucous membrane. 
When chronic poisoning results from the above causes or from 
the constant voluntary taking of certain poisonous drugs in 
minute quantities, disability more or less pronounced and pro- 
longed may ensue. 

Accident insurance policies sometimes pay a specific amount 
for death due to the accidental swallowing or inhalation of poison- 
ous drugs, but under such circumstances an insurance company 
makes a rigid investigation to make sure that the drug was ac- 
cidentally taken. When an individual swallows a drug for medi- 
cinal purposes and an overdose is taken either through his mis- 
take or that of another party, an insurance company would not 
pay a death indemnity should a fatal termination occur, for the 
reason that the drug is voluntarily swallowed, even though it 
may prove to be a toxic amount. A disability policy, however, 
in such cases would cover the period of total disability should the 
individual be prevented from attending to his occupation under 
the terms of the contract. When a person takes a poisonous drug 
intentionally in a sufihcient quantity to produce death, accident 
insurance poHcies sometimes provide a fixed sum as a death 
benefit. 

In the following articles the period given for house confine- 
ment, total and partial disability and partial indemnity for total 
disability is stated with the supposition that the taking of a pois- 
onous substances into the system, either by way of the alimentary 
canal or by inhalation, has been accidental in origin. 

ANTIMONY 

SYNONYMS: Tartar emetic; potassium and antimony tar- 
trate; tartrated or tartarized antimony; butter of antimony; 
Kermes mineral. 

INFORMATION: Antimony is frequently taken in poison- 
ous amounts, but on account of the vomiting which it produces 
in overdoses, the stomach is usually relieved of the poison and 
fatal effects do not occur. This drug is a gastro-intestinal irri- 
tant and also a strong cardiac depressant. It is said that with an 
adult a fatal dose has been as small as two grains, but generally 
to produce death a dram must be taken. If more than this quan- 
tity is swallowed, vomiting takes place at once. Antimony can 



ANTIMONY 529 

be applied externally, when it produces a papular eruption and if 
continued sufficiently long, destruction of the skin and under- 
lying tissues occurs, together with symptoms ot poisoning. Salts 
of antimony often contain arsenic as an impurity and this latter 
poison may complicate the former in some cases. 

SIGNS AND SYMPTOMS: When a poisonous dose of 
this drug has been swallowed, signs and symptoms usually ap- 
pear within one-half hour. There is first a metallic taste in the 
mouth and this is followed by nausea with violent retching and 
vomiting, accompanied by burning heat and pain in the mouth, 
throat and stomach. In addition the skin becomes moist and 
relaxed and this feeling of relaxation extends all over the body. 
Intense thirst is present, with a feeble rapid pulse, subnormal 
temperature and extreme prostration. Respirations are very 
shallow and irregular. The urine is usually increased in amount 
but occasionally suppression occurs;, it may or may not contain 
blood and sometimes is passed with considerable pain and diffi- 
culty. Purging occurs early and consists of first the contents of 
the intestines and this is followed by mucus and bile; blood very 
rarely being found in this discharge. The evacuations soon be- 
come very numerous and are known as 'Vice-water stools" re- 
sembling in this respect the discharges from a cholera patient. 
In cases where death does not take place for several days a pus- 
tular eruption may occur on the body, resembling that produced 
when the drug is applied externally. 

Chronic poisoning by antimony produces symptoms of con- 
stant nausea, with vomiting and purging, loss of appetite and 
muscular power, weak pulse, sweating, depression and finally col- 
lapse to be. followed by death from exhaustion. When death from 
any of the salts of antimony occurs, it follows great depression 
of the circulatory and respiratory functions. 

DIFFERENTIAL DIAGNOSIS : Arsenical Poisoning some- 
times complicates poisoning by antimony, as arsenic is often an 
impurity of this drug; being produced during its manufacture. 
Arsenic is also a gastro-intestinal irritant and causes practically 
the same signs and symptoms as antimony, but arsenical poison- 
ing can be differentiated from poisoning by this drug by the fact 
that in the former the stools always contain blood, while in the 
latter it is rarely found. The mucus contained in the evacuations 
of arsenical poisoning is usually in shreds, being stripped off the 
inside of the intestines, while in antimonial poisoning these 
shreds do not appear. Arsenical poisoning has a distinct romis- 
34 



530 MINERAL POISONS 






sion in the signs and S3qiiptoms, in which the individual appears 
to have started towards recovery; this is not present when anti- 
mony has been taken. A chemical analysis of the organs of the 
body— especially the liver — will show arsenic, while antimony 
is usually excreted by the bowels and kidneys. 

Asiatic Cholera is hard to differentiate from antimonial poi- 
soning when an epidemic of the former is existing. They both 
resemble each other, but cholera is generally accompanied by 
cramps in all the muscles of the body, whereas in poisoning by 
antimony these cramps appear only in the calves of the legs. 
Cholera is caused by the comma bacillus of Koch which can be 
shown to exist in the discharges from the intestines. 

HOUSE CONFINEMENT in cases which terminate fatally 
after this drug has been swallowed, seldom requires more than 
from I to 7 days. If an excessive dose is taken and ejected and 
recovery follows, house confinement of i to 2 weeks is usually 
sufficient. 

TOTAL DISABILITY following the accidental swallowing 
of antimony in which recovery ensues, requires in the majority 
of cases from 2 to 3 weeks. If death follows a fatal dose, total 
disability almost never demands more than 7 days, but this time 
is unimportant, because a policy that would cover an accidental 
death from this drug would pay the face of the policy only and not 
total or partial disabilit}^ in addition. 

PARTIAL DISABILITY due to the gastro-intestinal irri- 
tation which results from the taking of this drug may persist for 
some time and require from 2 to 4 or 6 weeks of this form of in- 
demnity. 

EFFECTS : When a history of accidental antimonial poi- 
soning exists, insurance of all kinds would be denied such an in- 
dividual until at least one to two 3^ears after the date of poisoning, 
for the reason that a chronic gastro-intestinal irritation is pres- 
ent and fatty degeneration of the organs of the body may be pro- 
gressing. 

■ POSTMORTEM APPEARANCES: The mucous mem- 
brane of the mouth, throat, stomach and small intestines is 
usually inflamed and softened, dark viscid mucus is found ad- 
herent to the mucous membrane of the intestines. The lining of 
the stomach may be infiltrated with blood and sometimes shows 
a pustular eruption. The brain, lungs and some of the organs of 
the abdominal cavity are congested and if death has not followed 
immediately, the liver generally shows fatty degeneration and 



ARSENIC 531 

this may be found in other organs. When death occurs from 
chronic poisoning, the large intestine reveals evidence of a long 
standing inflammation. 

ARSENIC 

SYNONYMS: Poisoning by Paris green; rough on rats; 
Scheele's green (copper arsenite). 

INFORMATION: Poisoning from arsenic itself is seldom 
seen, but arsenical poisoning — as it is commonly called — is al- 
ways due to one of its various salts; arsenious acid is the one 
most commonly used in the arts and therefore the one most fre- 
quently taken accidentally or wdth suicidal intent. It is the poi- 
sonous part of Paris green and rough on rats and as these two 
substances can be purchased without any trouble, poisoning by 
intent is often the result of the taking of one of these prepara- 
tions. Arsenic will produce symptoms of poisoning whether 
taken internally or applied to the mucous membrane and also the 
skin, if sufficient time is allowed for its absorption. A fatal dose 
of this drug varies, .but usually two to three grains will produce 
death within a few hours or a few days. If larger quantities are 
taken, vomiting generally occurs and if enough has not already 
been absorbed recovery takes place. 

SIGNS AND SYMPTOMS when a poisonous dose of this 
drug has been swallowed usually show themselves within a half 
to one hour, although they may not appear until from six to ten 
hours. Arsenic being a gastro-intestinal irritant produces a burn- 
ing sensation in the throat, with nausea, violent vomiting and 
purging. The evacuations from the bowels consist first of the 
contents of the intestines and then become the characteristic 
''rice-water stools" with the exception, however, that they con- 
tain blood. The burning sensation in the throat soon becomes a 
severe pain in the throat, stomach and intestines: intense thirst 
is present, together with frontal headache, dizziness, photopho- 
bia and usually, general prostration. The respirations arc shal- 
low and painful, the pulse feeble, of low tension, irregular and 
increased in frequency. The urine is scanty and somotimos sup- 
pression occurs. If death does not take place within twenty-tour 
to forty-eight hours, a remission of all the signs and symptoms 
occurs and oftentimes a favorable prognosis is given. This in- 
terval, however, is soon followed l)y a return of the pain, vomit- 



532 MINERAL POISONS 

ing, purging, etc., and death generally occurs on the fourth or 
fifth day, ending by convulsions or coma. 

Chronic poisoning which is produced when small doses are 
taken intentionally or administered by another party by intent 
results in anorexia, thirst, pains in the abdomen, diarrhea, head- 
ache, sleeplessness, pufhness beneath the eyes and a cutaneous 
eruption which resembles herpes zoster. In addition to the 
above there is nervous irritability, loss of weight, sometimes a 
tingling sensation in the extremities, falling out of the hair and 
impairment of the mental faculties. Pigmentation sometimes oc- 
curs and persists. The kidneys are usually afifected in chronic 
poisoning, showing a diminished excretion of urine which often 
contains blood and albumin. 

DIFFERENTIAL DIAGNOSIS between arsenical and an- 
timonial poisoning and cholera is considered under the previous 
article — Antimony. 

HOUSE CONFINEMENT is extremely short in fatal cases 
of acute poisoning by this drug; sometimes not lasting over a 
few hours. The usual period, however, is from i to 5 days; when 
recovery ensues, from i to 2 weeks are generally sufficient. 
Chronic cases in which the drug has been administered unknown 
to the individual cause house confinement of from i to 2 or 4 
weeks before death takes place. 

TOTAL DISABILITY is short following acute cases of 
poisoning by arsenic and rarely lasts more than from 2 to 4 or 6 
days when a fatal termination occurs. If recovery follows, total 
disability of from i to 2 or 3 weeks is usually demanded. Chronic 
cases of poisoning in which the drug has been taken for some 
time until finally disability ensues, generally require from 2 to 4 
or 6 weeks of this form before the occupation can be partially re- 
sumed or a fatal termination follows. 

PARTIAL DISABILITY would only be allowable where a 
non-fatal dose of this drug has been taken accidentally, and in 
such cases from i to 2 or 3 weeks are usually sufficient. 

EFFECTS: If recovery takes place after acute arsenical 
poisoning, such a person is uninsurable for any kind of insurance 
until at least one to two years have elapsed from the date of re- 
covery, on account of the fatty degeneration which may follow 
poisoning from this drug. Cases of chronic poisoning whether 
taken intentionally or administered by unknown parties would 
render the individual uninsurable for any kind of a policy until 



BISMUTH 533 

two to four years have elapsed and no untoward effects are shown 
to exist by a medical examination. 

POSTMORTEM APPEARANCES: Arsenic exerts its 
principal effects on the stomach and bowels, whether taken in- 
ternally or absorbed through the skin. The mucous membrane 
is inflamed and detached in spots, this inflammation extending- 
into the small and large intestines. The colon and often the rec- 
tum show evidence of a violent inflammation with ulcers of the 
mucous membrane of the rectum. The inflammation is more 
marked in the stomach, when death from acute poisoning occurs. 
When death follows within a few days, small red spots of in- 
flammation are found in the stomach and these spots usually con- 
tain arsenic. The blood is of darker color than normal and the 
liver and kidneys show fatty degeneration. When arsenic has 
been taken into the body, putrefactive changes are greatly re- 
tarded and the drug can be detected in most of the organs of the 
abdominal cavity; the liver especially containing a considerable 
quantity. 

BISMUTH 

INFORMATION : This drug is said to have caused death 
in some few cases when taken internally or used as an external 
dressing. It is believed, however, that in these cases the bismuth 
was contaminated with arsenic, lead or mercury and these drugs 
produced the s3^mptoms and caused the death. 

SIGNS AND SYMPTOMS produced by bismuth in poison- 
ous doses are gastro-intestinal in character with a metallic taste 
in the mouth, dark discoloration of the tongue, tenderness of the 
gums and diarrhea. The urine in fatal cases contains albumin 
and casts. 

DIFFERENTIAL DIAGNOSIS : When bismuth is claimed 
as causing signs and symptoms of poisoning, impurities which 
may contaminate it must be eliminated and usually when this 
process is taken up, the drug is found to contain arsenic, lead or 
mercury. Therefore, symptoms of poisoning from bisnuith are 
generally referable to the impurity which may be found existing. 

HOUSE CONFINEMENT when poisonous doses of bis- 
muth have been taken last from i to 2 or 3 weeks; this time de- 
pending on the amount and character of the impurities which the 
drug contains. 

TOTAL DISABILITY in poisoning from bisnuith gen- 



534 MINERAL POISONS 

erally lasts from 2 to 3 weeks when recovery takes place suffi- 
ciently for the occupation to be at least partially resumed. Fatal 
cases from poisoning by this drug are extremely rare and in one 
that has been reported, death occurred within nine days. 

PARTIAL DISABILITY is not often deserved following 
poisoning from bismuth unless the period of disability has been 
short, when i to 2 weeks of this form may be allowed in some 
cases. 

EFFECTS : After recovery from reported cases of bismuth 
poisoning in which the period of disability has been short, insur- 
ance of all kinds can be safely issued six to twelve months later. 

CARBOLIC ACID 

SYNONYMS: Poisoning by creosote; phenol; phenic acid; 
phenylic alcohol. 

INFORMATION : Carbolic acid is perhaps more frequently 
used as a means of suicide than any other poisonous drug. It is 
cheap and easily procured and when taken in sufficient quantities 
produces death within a very short time. The commercial car- 
bolic acid — which is the form employed — consists of crystals dis- 
solved in water or gtycerine. A fatal dose of this drug varies, 
but usually if an ounce of impure acid is swallowed death takes 
place immediately or within a few hours. Children are more sus- 
ceptible to the poisonous effects than are adults and in the latter 
if a poor physical condition exists, a smaller quantity of the acid 
will produce fatal results. 

SIGNS AND SYMPTOMS: Carbolic acid is one of the 
most rapidly acting poisons known and may produce death when 
taken in a sufficient quantity within a few minutes; in such cases 
the cause is respiratory failure. When a fatal termination does 
not occur at once, a severe gastro-intestinal irritation results and 
shows itself by burning in the mouth, throat and stomach to be 
followed by violent vomiting and purging. All the signs and 
symptoms of collapse are present, such as cold, sweating skin, 
weakened pulse, shallow and painful respirations. Contraction 
of the pupils, with a slow reaction to light and insensibility of the 
cornea exist. The urine is passed with difficulty in a lessened 
amount and occasionally entirely suppressed, it is of a dark green 
color and this becomes more marked on standing; the color, how- 
ever, is not due to blood, but to a chemical compound. 

DIFFERENTIAL DIAGNOSIS : The odor of carboHc acid 



CARBOLIC ACID 



is usually detected when the drug has been swallowed, although 
it may not be perceptible. Wherever the acid comes in contact 
with the skin or mucous membrane, it produces an eschar which 
IS pathognomonic. The mucous membrane is corrugated and of 
a white color if the pure drug has been taken. If impure the 
membrane is corrugated, but stained black. These eschars have 
a white center which is surrounded by a red and inflamed area. 
This white center sometimes becomes dark brown or black. A 
dark green, smoky urine, with the characteristic eschars, con- 
tracted pupils and profound insensibility are sufficient to make 
the diagnosis of carbolic acid poisoning. 

HOUSE CONFINEMENT in fatal cases rarely lasts long 
enough to be considered; death usually occurring from within a 
few minutes to 6 to 12 hours. If recovery follows, house confine- 
ment lasts from i to 2 or 4 weeks; this time depending on the 
amount of acid swallowed, the physical condition of the individual 
at the time it was taken, the rapidity with which treatment was 
instituted, the shock and the resulting effects on the throat, 
stomach and kidneys. 

TOTAL DISABILITY is not payable under an accident 
pohcy when this drug is taken accidentally and death results, as 
the company if liable for any sum would be liable for the amount 
specified in the policy and not any indemnity for total disability. 
If recovery takes place, total disability of from 2 to 4 or 6 weeks 
is usually demanded; this time depending on the conditions 
enumerated under house confinement. 

PARTIAL DISABILITY is often claimed when the period 
of total disability is ended and in some cases is deserved; when 
payable from 2 to 4 weeks are ample. 

EFFECTS : When carboHc acid has been swallowed and re- 
covery ensues, contraction follows wherever the acid has touched 
the mucous membrane. These contractures when involving the 
esophagus may produce stricture and thus render the risk unin- 
surable for any kind of insurance. If no effects are observable 
after two to four years have elapsed, insurance of all kinds couUl 
be considered. 

POSTMORTEM APPEARANCES: The nuicons mem- 
brane of the mouth, esophagus and stomach is corroded, whitened 
and easily removed. It may, however, be hardened and corru- 
gated. The brain is congested, the blood darker, the bladder 
usually empty, if not, it contains a small quantity of smoky urine, 
and all the fluids of the body, including the blood, give otT the 



536 MINERAL POISONS 

odor of phenol. Hare states that a peculiar croupous exudate 
is sometimes found in the bronchial tubes and Langerhaus has 
noted that in some of these cases, evidence of croupous pneu- 
monia existed. Fatty degeneration of the organs may follow 
when death has been due to this poison. Rigor mortis follows 
early when death results from this cause and postmortem stain- 
ing appears at once. 

COPPER 

SYNONYMS: Blue vitriol; blue stone. 

INFORMATION: When indemnity is claimed for poison- 
ing due to one of the salts of copper it is usually accidental in 
origin, for the reason that very few people attempt suicide with 
any of these salts. Accidental poisoning by this metal generally 
results from eating substances which have been cooked in cop- 
per or tinned-copper vessels. It is claimed that the copper itself 
is not poisonous, but when introduced into the stomach and acted 
upon by the gastric juice, a chemical reaction takes place and 
produces an irritant substance, which causes signs and symptoms 
of poisoning. Copper is often contaminated with arsenic and in 
such cases the illness is probably due to both poisons. The fatal 
dose of this poison is uncertain; large doses usually produce 
vomiting and thus recovery follows. One-half ounce of verdigris 
(impure acetate of copper) has produced fatal results, while one 
ounce of the sulphate has also resulted in death. 

SIGNS AND SYMPTOMS begin within two to four hours 
after the ingestion of substances contaminated with copper. A 
coppery taste in the mouth is complained of and this is followed 
by nausea and vomiting; the vomited matter being of a blue or 
green color. Severe pain in the abdomen with flatulence and 
diarrhea are present in such cases. The character of the diarrhea 
is black or reddish-brown and is streaked with blood. Head- 
ache, dizziness, coldness of the extremities, with dyspnea and 
sometimes tetanic convulsions occur. The pulse is weak, feeble 
and rapid, while the urine is scanty and sometimes suppressed. 
Jaundice is frequently seen. 

Chronic poisoning by copper produces emaciation, metallic 
taste in the mouth, anorexia, thirst, a sallow complexion, with 
cramps and colicky pains, vomiting and diarrhea with black or 
greenish stools streaked with blood The kidneys are aiTected, 
causing a lessened amount of urine to be excreted and sometimes 



COPPER 537 

suppression results. Jaundice occurs and is said to be due to 
atrophy of the liver. 

DIFFERENTIAL DIAGNOSIS: When a case of poison- 
ing by copper is seen it is not difficult to make the diagnosis, as 
this drug imparts a blue or greenish color to the mouth and 
tongue and the vomited matter. When bile is vomited, it may 
resemble the color due to copper poisoning, but in such cases if 
aqua ammonia is added to it the color remains unchanged, while 
if the color is due to poisoning by copper it becomes a deep blue. 
The drug is a gastro-intestinal irritant and produces signs and 
symptoms similar to other drugs in the same class. In addition 
if the case does not terminate fatally within a few hours, jaundice 
appears and this sign is not frequent when other drugs are 
taken in poisonous doses. 

HOUSE CONFINEMENT in fatal cases of acute poison- 
ing by copper seldom lasts over i to 2 days; death in the majority 
of cases usually taking place within ten to twelve hours. Chronic 
poisoning may require house confinement of from i to 2 or 3 
weeks. 

TOTAL DISABILITY: When acute copper poisoning pro- 
duces a fatal termination, it rarely requires more than i to 2 
days. Non-fatal cases usually result in an acute gastro-enteritis 
and require from i to 2 weeks of this form of disability when it is 
positively known that the cause was acute copper poisoning. 
Cases of chronic poisoning are totally disabled from 2 to 4 weeks; 
this time depending on the amount of poison ingested, the efTect 
it has had on the general physical condition, the occupation and 
the rapidity with which elimination can be effected by other 
drugs. 

PARTIAL DISABILITY of i to 2 weeks is sometimes de- 
served in cases of chronic poisoning by copper. 

EFFECTS : When recovery takes place after acute or 
chronic poisoning by copper, such a person is uninsurable for any 
kind of insurance until two to three years after complete recov- 
ery. Copper may produce atrophy or fatty degeneration of the 
liver and in some cases parenchymatous nephritis develops. 

POSTMORTEM APPEARANCES are not especially char- 
acteristic. There is evidence of inflammation involving the gas- 
tro-intestinal tract, with a bluish discoloration of the nuicou> 
membrane of the esophagus, stomach and intestines. Perfora- 
tion of the stomach and intestines has occurred when death was 



538 MINERAL POISONS 

due to poisoning by copper and small particles of this drug have 
been found adhering to the mucous membrane of the bowels. 

HYDROCHLORIC ACID 

SYNONYMS: Muriatic acid; spirit of salt 

INFORMATION: Hydrochloric acid as found in com- 
merce consists of the gas dissolved in water and when pure it is 
colorless, but the commercial acid is usually of a yellowish color. 
Poisoning by this acid does not often occur, as exposure to the 
air results in fumes which attract attention and prevent the acid 
being taken accidentally. The smahest fatal dose on record is 
one-half ounce of the commercial acid. 

SIGNS AND SYMPTOMS: In poisoning by this acid the 
corrosive action is not so marked as when some of the strong 
acids are used. There is severe burning pain in the mouth, throat 
and stomach, with violent vomiting of the contents of the 
stomach and shreds of mucous membrane; the vomited matter 
being decidedly acid in reaction. Thirst, rapid, feeble pulse, great 
prostration and sometimes suppression of urine occurs. If this 
acid has been quickly swallowed the fumes may be inhaled, when 
a violent cough and bronchitis are set up and this may produce 
death within a few minutes by edema and spasm of the glottis. 

DIFFERENTIAL DIAGNOSIS: Hydrochloric Acid when 
swallowed produces a white discoloration of the skin and mucous 
membrane, but no corrosion occurs. When the acid is spilled 
on some part of the clothing the color is changed or destroyed, 
but the texture is not often ruined. White fumes are given off 
from the mouth and also from the vomited matter and the char- 
acteristic odor of the gas is easily detected. 

Nitric Acid when ingested produces a violent gastro-intesti- 
nal irritation and white stains on the skin, mucous membrane of 
the lips and gums. These stains soon become yellow and then 
a reddish-brown. The vomited matter is yellow or orange color 
and gives off the odor of orange. When the acid has touched 
the clothing the spots are first yellow and then become a reddish- 
brown. 

Stdphuric Acid also produces a violent gastro-enteritis, with 
an immediate destruction of the tissues with which it comes in 
contact. The vomited matter is black or brown and often in- 
cludes portions of the muscular coat of the esophagus. Blood 
which may be vomited resembles coffee-grounds in appearance. 



HYDROCYANIC ACID 539 

Sulphuric acid stains the hps and mucous membrane of the mouth 
a brown color; this, however, in the early stages may be white 
gradually turning to a dirty brown or black. 

HOUSE CONFINEMENT in fatal cases lasts from i to 3 
days and in non-fatal ones this period may be prolonged from 2 
to 3 or 4 weeks; this time depending on the amount of acid swal- 
lowed, the degree to which the tissues have been destroyed and 
the physical condition of the individual before the acid was taken. 
TOTAL DISABILITY lasts from i to 3 days in fatal cases, 
although if a sufhcient quantity be taken death may ensue within 
a few hours. Cases of poisoning by hydrochloric acid which re- 
cover, are totally disabled from 2 to 4 or 6 weeks and sometimes 
longer. The period of total disability depends mainly on the 
amount of acid swallowed and the destruction of tissue which 
follows, together with the rapidity with which nature repairs the 
damaged parts. 

PARTIAL DISABILITY is payable to individuals who re- 
cover after accidentally taking hydrochloric acid; in such cases 
from 2 to 4 weeks are generally considered sufficient. 

EFFECTS ; When this acid has been taken and recovery 
ensues, such a person is uninsurable for any kind of a policy until 
at least one to two years have elapsed after complete cessation of 
all symptoms, and even at this time if much destruction of tissue 
has occurred, it is questionable if any form of insurance should 
be issued on account of strictures of the esophagus which may 
exist. 

POSTMORTEM APPEARANCES; Stains about the 
fingers, mouth and any other part of the body or clothing with 
which the acid has come in contact are usually yellowish-brown 
in color. The mouth and esophagus are also stained dark and 
sometimes the mucous membrane has been stripped oil. The 
mucous membrane of the stomach may also be of a brown or yel- 
low color and beneath evidence of infianmiation is apparent. The 
elottis is swollen and inflamed and when the drui^- has Ihxmi in- 
haled while being swallowed and a physician sees the case im- 
mediately, there may have been performed a quick tracheotomy. 
Disorganization of the tissues is not so pronounced as when some 
of the more corrosive acids have Iuxmi taken. 

HYDROCYANIC ACID 

SYNONYMS; Prussic aci\l; Sclioolo's acid. 



540 MINERAL POISONS 

INFORMATION: Hydrocyanic acid is one of the most 
deadly, quickly acting poisons known and when taken internally 
it is done so in a solution which usually contains two per cent, 
only. It is a very volatile acid and the fumes from the drug cause 
death almost as quickly as when a fatal dose is swallowed. One 
dram of a two per cent, solution of this acid is sufhcient to cause 
death. Two to four ounces, however, are generally required to 
cause a fatal termination. Prussic acid is one of the constituents 
of bitter oil of almonds; this oil containing from two to four per 
cent, of the drug. Scheele's acid contains about five per cent, of 
hydrocyanic acid and the official French preparation contains ten 
per cent, of this acid. Hydroc3'anic acid is also found in the ker- 
nels of apples, plums and peaches; the latter containing the larger 
percentage. One and one-half ounce of peach kernels will yield 
about one grain of hydrocyanic acid and this amount is more 
than sufficient to cause death. Potassium cyanide is largely em- 
ployed in certain lines of manufacture and poisoning from this 
frequently occurs; the signs, symptoms and postmortem appear- 
ances being the same as that produced by hydrocyanic acid. 
Three to five grains of potassium cyanide are usually fatal. 

SIGNS AND SY]\IPTOMS: A small or non-fatal dose of 
hydrocyanic acid produces unconsciousness, shallow, irregular 
breathing, complete muscular relaxation, involuntary evacuations 
from the bladder and bowels and oftentimes violent convulsions 
and general paralysis. If a large fatal dose is taken, death may en- 
sue before the full amount is swallowed and it almost always takes 
place within three to seven or ten minutes, rarely being post- 
poned twenty to thirty minutes. When a fatal dose is swallowed 
the individual falls to 'the ground with a single gasp or shudder, 
the respirations being discontinued at once and froth tinged with 
blood oozing from between the lips; the jaws are firmly fixed, 
the pupils dilated and the eyeballs staring and protruding, the 
skin is cyanotic, involuntary evacuations occur, the pulse gen- 
erally becomes weakened until it is imperceptible and muscular 
relaxation, with absence of all reflexes follows. If sufficient fumes 
of the drug are inhaled to produce a fatal termination, the signs 
and symptoms are the same as if the drug was taken internally. 

DIFFERENTIAL DIAGNOSIS in fatal cases is never made 
until after death, for the reason that this occurs so rapidly that 
usually medical attendance never reaches a person until too late 
to be of any assistance. The odor of the acid is perceptible when 



HYDROCYANIC ACID 54I 

a case is seen shortly after it has been swallowed and helps the 
physician in forming an idea as to the cause of death. 

Nitrohenzol produces symptoms similar to prussic acid, but 
as it also causes death as quickly, the diagnosis is unimportant for 
the purpose of treatment. After death the odor of nitrobenzol 
persists, while the detection of prussic acid by smell can only be 
■done at once after opening the body. 

HOUSE CONFINEMENT for persons who have taken a 
dose too small to produce death is short, not often lasting over 
2 to 4 or 7 days. When a fatal termination occurs there is no 
house confinement, death taking place almost immediately in all 
•cases. 

TOTAL DISABILITY in cases which recover from a non- 
fatal dose of hydrocyanic acid rarely require more than i week. 
When a fatal termination occurs and is accidental in origin, an 
insurance company according to the wording of the policy would 
be liable or not for a specified amount. If the death is suicidal, 
the majority of insurance companies pay a fractional part of the 
face of an accident policy; there being a condition to that effect 
in the contract. 

PARTIAL DISABILITY is never payable from poisoning 
by this acid as the individual is able to resume all the duties of 
the occupation as soon as part of them can be taken up. 

EFFECTS : After a non-fatal dose has been swallowed or. 
inhaled accidentally and recovery follows such a person would 
be insurable for all kinds of insurance three to six months after 
the date of accident, provided a medical examination showed the 
kidneys to be normal. If the drug was taken with suicidal intent 
and recovery followed, insurance of all kinds would be denied 
such an individual. 

POSTMORTEM APPEARANCES: When death occurs 
from the ingestion of hydrocyanic acid the face is pale or cyanosed, 
the eyes open and staring, the pupils dilated and evidence of 
bloody froth is seen in the mouth; the jaws being tightly closed. 
The vessels of the head and neck are usually engorged with 
blood, the hands are clenched and sometimes bright red spots 
are seen scattered over the surface of the body. The odor of prus- 
sic acid is perceptible in many cases before an autopsy is per- 
formed and this odor can almost always be detected when the 
■stomach is first opened, although it disappears quickly after the 
■contents of the abdomen are exposed to the air. \\'hon not per- 
ceptible on the opening of these organs, it can somotinios be de- 



542 MINERAL POISONS 

tected when the skull is first opened. The venous system is en- 
gorged with blood and if death has occurred rapidly, the small 
arteries contain arterial blood and the large ones venous blood. 
All the organs of the body are found congested, the heart is soft 
and flabby, the mucous membrane of the stomach is inflamed and 
sometimes postmortem rigidity is excessive. 

LEAD 

SYNONYMS: Poisoning by lead acetate (Sugar of Lead); 
lead subacetate (Goulard's Extract) ; lead carbonate (White Lead, 
Ceruse). 

INFORMATION: Lead or plumbum is a metal which is 
not poisonous in itself, but some of its salts are highly injurious 
and produce marked signs and symptoms when taken in poison- 
ous doses. Poisoning by this drug is divided into the acute and 
chronic forms. Acute poisoning is due to the ingestion of quan- 
tities which produce the acute signs and symptoms, and chronic 
poisoning follows the slow assimilation of this drug during its 
manufacture or in the manufacture of articles which require its 
use. Acute lead poisoning is not often seen and when met with 
it is usually accidental. This drug is sometimes employed by 
criminals for the purpose of producing sickness or death in other 
individuals, but it is easily detected. 

SIGNS AND SYMPTOMS : Acute lead poisoning when it 
occurs commences with a persistent, sweet, metallic taste in the 
mouth, thirst, headache and a sense of constriction in the throat. 
These symptoms come on within two to twelve hours and are 
followed by pain in the epigastrium, nausea and vomiting of the 
contents of the stomach and a milky fluid which contains white 
curds; these curds being due to the formation of insoluble lead 
chlorid by the action of the h3^drochloric acid of the stomach. 
The pain in the epigastrium is more pronounced around the um- 
bilicus and is usually relieved by pressure. The abdominal mus- 
cles are rigid, the urine is scanty or suppressed and muscular 
cramps of the calves of the legs, with neuralgic pains frequently 
occur. Constipation generally follows acute lead poisoning but 
when a movement of the bowels takes place, the stools are usually 
black; this color being due to the sulphide of lead. The pulse 
is at first rapid and tense, but soon becomes weak and compress- 
ible. In some instances collapse, coma and convulsions ensue and 
end the case. 



1 



II 



LEAD 543 

Chronic lead poisoning begins insidiously, the symptoms be- 
ing obscure and not easily traced to this drug. Indigestion with 
fetid breath, coated tongue, headache and colicky pains in the 
abdomen which center around the umbiHcus and are reheved by 
pressure, are some of the early signs and symptoms of this form 
of poisoning. In addition there is obstinate constipation and 
when a movement does occur, the stools are white or clay color. 
The flow of urine is scanty or suppressed and the arterial tension 
is markedly increased. A characteristic and pathognomonic sign 
of this poisoning is the blue spots or line on the gums near the 
teeth. The gums in such individuals are tender and bleed easily 
and sometimes the teeth show a brownish discoloration. If ex- 
posure to the drug is not stopped, paralysis of the extensor 
muscles of the forearm occurs and results in "wrist drop." The 
muscles become atrophied and occasionally pain in the joints ap- 
pears in this form of poisoning. 

DIFFERENTIAL DIAGNOSIS of poisoning when sup- 
posed to be due to lead is partly made by the character of the pain 
and its location. Lead poisoning produces cramps or coHc in the 
abdomen which center around the umbilicus and are relieved by 
pressure. Obstinate constipation, with the passage of clay col- 
ored stools, the blue spots or line on the gums and wrist drop 
are characteristic of this form of poisoning. 

HOUSE CONFINEMENT following acute poisoning by 
lead is uncertain; lasting from 2 to 3 days to i to 2 weeks. A 
fatal termination, however, when it occurs usually does so within 
2 to 7 days. Chronic poisoning causes house confinement of from 
I to 3 or 4 weeks; this time depending on the degree to which 
the individual has been exposed and the rapidity with which the 
system eliminates the poison. 

TOTAL DISABILITY following cases of acute poisoning 
when a fatal termination ensues rarely requires more than i week. 
If recovery takes place, total disability of from i to 3 weeks is 
often necessary. Chronic poisoning by this drug would not be 
covered by an accident policy, and a health policy would only do 
so when the occupation of the individual was known to the com- 
pany at the time the policy was issued. In such cases total dis- 
ability of from 2 to 3 or 4 weeks is often required, when it finally 
ensues after prolonged exposure to lead and chronic poisoning- 
results. 

PARTIAL DISABILITY is not often payable to individuals 



544 MINERAL POISONS 

suffering with acute lead poisoning when it is accidental in origin. 
When payable, however, i week is usually ample. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
following chronic lead poisoning after the termination of house 
confinement may require from i to 3 or 4 weeks; this time de- 
pending on the emaciation and weakness which result from the 
poisoning and the rapidity with which the drug is eliminated and 
the normal physical condition regained. 

EFFECTS: Individuals with a history of having suffered 
from acute lead poisoning which is accidental in origin, are in- 
surable for all kinds of insurance from two to three months after 
complete recovery. When disabihty has resulted from chronic 
lead poisoning or repeated attacks of lead colic have taken place, 
an insurance company would not issue a life or health policy, al- 
though an accident policy might be granted by some companies., 

POSTMORTEM APPEARANCES when death has been 
due to acute lead poisoning are not characteristic. There may be 
an inflammation of the gastro-intestinal tract, with a deposit of 
sulphid of lead on the mucous membrane causing a grayish ap- 
pearance. When death has not occurred early, the colon is con- 
stricted and a blue hne or spots appear on the gums. The blue 
line on the gums, however, may be absent in persons who are 
exceptionally careful about cleanliness of the mouth. If a death 
occurs from chronic poisoning, a blue line or spots on the gum 
— if present — is a characteristic and important sign, the colon is 
found constricted and thickened and a grayishness of the mucous 
membrane exists. The kidneys are contracted and show a fatty 
or granular degeneration. The extensor muscles of the forearm 
are atrophied and the elasticity of the arteries is greatly dimin- 
ished. 

MERCURY 

INFORMATION : Poisoning by mercury is of two kinds, — 
that due to the mercuric salts which are corrosive in action and 
produce acute signs and symptoms, — and the mercurous salts 
which are generally the ones concerned in chronic poisoning. 
Acute poisoning is usually due to corrosive sublimate (bichlorid 
of mercury, mercuric chlorid) when this drug is swallowed acci- 
dentally or by intent. Accidental poisoning by corrosive subli- 
mate frequently occurs and is due to the fact that when corrosive 
sublimate is dissolved in water and uncolored, the solution re- 



MERCURY 545 

sembles in every respect ordinary drinking water. Chronic poi- 
soning by mercurous salts of mercury generally occurs to indi- 
viduals who are exposed to this drug in the manufacture of arti- 
cles which require its use. The smallest fatal dose of a mercuric 
salt is said to have been three grains; the average fatal dose being 
four to five grains. 

SIGNS AND SYMPTOMS of acute poisoning by corrosive 
sublimate appear very quickly, usually beginnmg within one-half 
hour after the poison has been swallowed. A metallic taste is 
complained of, with a burning pain in the mouth, throat and 
stomach and this gradually extends over the abdomen and is in- 
creased by pressure; thirst with nausea and vomiting of blood- 
stained mucus and diarrhea occur; the stools being largely com- 
posed of blood and mucus. The urine is scanty or suppressed. 
The face is flushed and swollen, the pulse is rapid and wiry, dysp- 
nea is present and sometimes the local effect of the drug on the 
mucous membrane is so great that edema of the glottis occurs 
and death quickly follows. The lips and tongue are white and 
shrivelled from the effects of the drug and its affinity for albu- 
minoids. 

Chronic poisoning is due to a slow absorption of the mer- 
curous salts of mercury, either through the skin from mercurial 
ointments or the inhalation of fumes in which this drug is carried 
and by the alimentar}^ canal when small repeated doses are given. 
The most important sign of chronic poisoning by mercury is 
ptyaHsm, this appearing several days after the drug has been 
taken. The flow of saliva is excessive and large amounts are se- 
creted. In addition there is loss of appetite, metallic taste in the 
mouth, the teeth become loosened, the gums are swollen, tender, 
painful and ulcerated, and at the edge of the gums Avhere they 
meet the teeth, a bluish-gray substance appears The breath is 
fetid and deterioration of the blood occurs, it becoming more 
fluid than normal. Sometimes this drug affects the nerve centers 
when a peculiar tremor first occurs in the upper extremities and 
gradually extends and involves all parts of the body. It is popu- 
larly known as shaking palsy. These tremors usually disappear 
when the individual is asleep. Death from chronic poisoning is 
generally preceded by convulsions and coma. 

DIFFERENTIAL DIAGNOSIS: Arsenical Poiscviiii}: nmst 
be differentiated from that produced by mercury. In the former, 
the signs and s^nnptoms rarely come on under an hour, for the 
reason that arsenic is less soluble than is mercurv. Arsenic does 



546 MINERAL POISONS 

not produce the white shrivelled appearance of the mucous mem- 
brane and while the stools in poisoning from both drugs contai-i 
blood, those due to mercurial poisoning usually show larger 
quantities. Death from mercurial, poisoning generally takes 
place within a shorter time than death due to arsenical poisoning. 
Examination of the urine, saliva and feces shows the presence of 
mercury which can be detected in the urine and saliva within 
three to six hours after being swallowed. 

_ HOUSE CONFINEMENT in fatal cases of mercurial poi- 
soning is short; death sometimes occurring within twenty-four 
hours. In the majority of cases, however, a fatal termination 
takes place within i to 5 days. Chronic cases of poisoning by 
this drug require from i to 2 or 3 weeks of house confinement; 
at the end of which time the individual is usually sufficiently re- 
covered to be taken into the open air and kept there. Confine- 
ment to the house is not necessary in cases of chronic poisoning 
unless the symptoms come on acutely, when the above time is 
ample. 

TOTAL DISABILITY following acute cases of mercurial 
poisoning seldom lasts over 7 days, as death usually occurs within 
that time. Should recovery take place, however, from 2 to 4 
weeks are generally required before a part of the occupation can 
be resumed. When total disability is reported to have been 
caused by chronic mercurial poisoning, a close investigation of 
the claim must be made, for the reason that in the majority of 
cases the individual has mis-stated the occupation at the time ap- 
plication was made for the policy. If total disability follows 
chronic poisoning, from 2 to 4 or 6 weeks are necessary, 

PARTIAL DISABILITY of i to 2 weeks is sometimes de- 
manded in cases of acute poisoning which are accidental in origin. 
When chronic poisoning occurs, from i to 4 weeks may some- 
times be required. Partial indemnity for total disability when due 
to chronic poisoning after the termination of house confinement, 
should not be allowed, because in the majority of cases the occu- 
pation has been the cause of the poisoning and it has been mis- 
stated in the application, thereby producing a breach of warranty. 

EFFECTS: Acute cases of accidental mercurial poisoning 
which are not terminated by death, would not be considered in- 
surable for life or health insurance until at least one year had 
elapsed after recovery was said to have been complete. The is- 
suance of an accident policy to such a person would depend 



NITRIC ACID 547 

greatly on the history of how the poisoning occurred. If the in- 
dividual was shown to have been careless and the occupation was 
favorable to a recurrence of the same condition, accident insur- 
ance would not be granted. If these conditions were not pres- 
ent it could be safely issued from two to four months after com- 
plete recovery. Chronic poisoning usually leaves the individual 
in impaired health, a number of teeth remaining loose, causing 
the food to be poorly masticated and indigestion results. Such 
cases would not be considered for Hfe or health insurance until 
at least one year after all signs and symptoms due to poisoning 
had disappeared. 

POSTMORTEM APPEARANCES: Acute cases of poi- 
soning followed by death from corrosive subHmate show an in- 
flamed condition of the mouth, throat, stomach and intestines; 
the mucous membrane of the mouth and throat being white or 
gray and corroded; this corrosion extending into the intestines 
sometimes as far as the colon. Small hemorrhages not uncom- 
monly occur beneath the mucous membrane of the stomach and 
I ulceration has occasionally been found. If death does not occur 
for several days, the lower part of the small intestines, together 
with the colon, often shows a higher degree of inflammation than 
does the stomach and is covered by a diphtheritic-like membrane. 
When a fatal termination follows chronic poisoning by this drug 
the gums are found to be soft and spongy, with or without a 
bluish-gray line on them and the teeth loosened. The epiphyses 
of the long bones are sometimes loosened and spongy, while the 
medulla of the shaft shows increased vascularity. Congestion of 
the kidneys exists, together with evidence of widespread degener- 
ation and deposits of chalky material. 

I NITRIC ACID : 

SYNONYM: Aquafortis. 

INFORMATION: Nitric acid is the strongest and most 
corrosive of the mineral acids and when acute poisoning occurs 
it is usually due to the concentrated form being taken or the 
fumes from it inhaled. When freshly prepared it is colorless, but 
on standing becomes a yellow or orange color and if uncorked, 
fumes are given off. This acid causes death when the concen- 
trated form is taken and when its fumes are inhaled. The smallest 
• quantity which is said to have produced death is two drams of 
the strongest acid. 

SIGNS AND SYMPTOMS depend on the manner in which 



548 MINERAL POISONS 

this drug is taken, — when swallowed or inhaled. In the former 
a violent gastro-enteritis is at once set up, with burning pain in 
the mouth, throat and stomach, nausea and vomiting of strong 
acid matter which is orange or brownish-black in color. Shreds 
of mucous membrane and disintegrated blood are ejected. Symp- 
toms of collapse such as cold clamni}' skin, rapid and weak pulse 
and feeble respirations are constant. If this acid is swallowed the 
fumes are sometimes inhaled, when edema of the glottis results 
and death quickh^ follows. Nitric acid causes a white stain on the 
skin and mucous membrane and this soon changes to yellow or 
orange, gradually becoming a reddish-brown and is very persist- 
ent. It leaves a yellow mark on clothing which dries and gradu- 
ally disintegrates the cloth. The fumes of this acid are sometimes 
inhaled when large quantities are spilled. In such cases there is 
cough, dyspnea, pain in the throat and chest, often nausea and| 
vomiting and prostration. Symptoms of pneumonia, together 
with prostration are slow in appearing, usually not showing until 
several hours after the fumes have been inhaled. A case of the 
author's experience occurring some years ago produced immedi- 
ate discomfort and was followed by a period of several days in 
which the individual while conscious, was dazed and unable to 
perform an}^ work. This in turn was followed by a period of calm 
in which labor was resumed and then disability again ensued and 
resulted in death twenty-nine days after the fumes were inhaled. 
Another individual in company with the one above described, 
also inhaled the fumes and after several hours disappeared and 
wandered around the country almost a week before being found. 
He, however, recovered after some weeks of disability. 

DIFFERENTIAL DIAGNOSIS between sulphuric, nitric 
or hydrochloric acid poisoning is tmimportant, as all three ai-e 
corrosive; the only difference between them being that sulphuric 
acid is the most destructive, nitric acid next and hydrochloric 
acid the least; all three produce violent gastro-enteritis. Nitric 
acid may be distinguished by the color of the stain, which is yel- 
low on clothing, and on the skin and mucous membrane it is first 
white, then yelloAV or orange and finally a brownish-red. 

HOUSE CONFINEMENT in fatal cases when concen- 
trated nitric acid has been swallowed seldom lasts over i or 2 
idays. If recovery takes place house confinement of from i to 2 
or 3 weeks may be necessary before the individual is able to go 
into the open air. Poisoning by the inhalation of the fumes of 
nitric acid may produce house confinement of from 3 to 7 days 



NITRIC ACID 549 

and this period be followed by a remission in which house con- 
finement does not exist. This is succeeded by another period of 
house confinement lasting from i to 2 or 3 weeks. 

TOTAL DISABILITY of i to 2 days is ample for fatal 
cases of nitric acid poisoning when the drug is swallowed. If re- 
covery follows the ingestion of a quantity of this acid total dis- 
ability is very uncertain, sometimes lasting only from 2 to 3 or 4 
weeks and again the same number of months may be necessary 
before the occupation can be partially resumed. 

PARTIAL DISABILITY is often demanded for long 
periods, when this acid has been accidentally swallowed or in- 
haled and death does not ensue at once; this is due to impairment 
of the digestive function and the cicatrices of the mucous mem- 
brane which follow wherever this acid touches. 

EFFECTS: Individuals having suffered from nitric acid 
poisoning", either by swallowing or inhaling the fumes, are unin- 
surable for any kind of insurance until at least three to five years 
have elapsed after recovery is said to have taken place and no 
untoward signs or symptoms result. 

POSTMORTEM APPEARANCES: The digestive tract 
from the mouth to the rectum shows evidence of a violent in- 
flammation with a yellowish discoloration of the mucous mem- 
brane which is softened and in man}^ cases eroded and some- 
times perforated. The stomach is distended with gas and con- 
tains disintegrated blood which is strongly acid in reaction. The 
lungs often show evidence of an inflammation and this is especi- 
ally pronounced when fumes of the drug have been inspired. The 
kidneys are congested and swollen and when death does not take 
place at once degeneration of the tissues occurs. In the author's 
case above mentioned, a postmortem examination showed the 
mucous membrane of the stomach to be corroded, of a dull red 
color and with numerous perforations, mostly on the posterior 
surface; the intestines were also corroded and perforated in spots. 
Both lungs were inflamed and showed minute perforations, the 
pleural cavity of each lung containing fluid and blood. The heart 
showed marked changes of degeneration, being soft, flabln- and 
easily torn and all four cavities contained a nunfluM- of perfora- 
tions; the larger number, however, being in the left \ontrio1e. 
The heart nuiscle was so friable that it could bo easily separated 
and pulled apart and the pericardiiuu ccMitained (luantities of dis- 
integrated blood. The kidneys, liver and spleen were swollen 
and congested. 



550 MINERAL POISONS 

PHOSPHORUS 

INFORMATION : Accidental poisoning by phosphorus 
does not often occur in the acute form, although chronic poison- 
ing from this drug by those engaged in the manufacture of 
matches frequently takes place. Phosphorus or that -contained 
in match heads is soinetimes employed with suicidal intent and 
this is especially true in continental countries. A fatal termina- 
tion from poisoning by this drug occasionally occurs within a 
short time, but usually some days elapse before death takes place. 
A very small quantity of phosphorus will produce death; one 
grain, however, being the average amount. 

SIGNS AND SYMPTOMS after a poisonous dose of phos- 
phorus has been swallowed usually appear within three to eight 
hours. This drug is a strong irritant, consequently a violent gas- 
tro-enteritis results and shows itself by a burning pain in the 
mouth, throat and stomach, accompanied b}^ belching of gas 
which has the odor of garlic and a disagreeable taste of garlic is 
constantly present. There is thirst, nausea, and vomiting which 
comes on early, the vomited matter consisting of first the con- 
tents of the stomach and later mucus, bile and sometimes blood; 
in all cases in the early stages it is luminous in the dark. Per- 
sistent hiccoughing frequently exists and is characteristic. Con- 
stipation is the rule in acute cases of phosphorus poisoning, but 
when a movement does occur — especially from twelve to twenty- 
four hours after the drug has been swallowed — the stools are 
luminous in a darkened room. The urine is scanty and albu- 
minous and bile-stained and may be entirely suppressed. The 
skin is cold and clam.my, the pupils are dilated, the temperature' 
is excessiveh^ high in the beginning and later becomes subnormal 
and the pulse is frequent, weak and irregular. If death does not 
occur until one to two days after the drug has been taken, jaun- 
dice is a prominent sign. When a fatal termination does not en- 
sue within a short time, a period of remission lasting from two 
to three days follows and during this time a favorable prognosis 
is frequently given. At the end of this period the signs and 
symptoms suddenly reappear, usually beginning with jaundice 
which afifects the whole body and bleeding from the nose and 
mucous membrane and hemorrhages under the skin. The urine 
becomes highly albuminous and contains fat globules and bile 
pigments. The liver is greatly enlarged, the abdomen is tympa- 



PHOSPHORUS 551 

nitic and twitching of the muscles, with convulsions and coma 
precede the death. 

Chronic poisoning by phosphorus due to the inhalation of 
fumes of this drug in the manufacture of matches, comes on in- 
sidiously and is characterized by bronchitis, pains in the joints^ 
emaciation and destruction of the teeth and bones of the jaw. 
When this form of poisoning affects an individual, necrosis of 
the bones of the upper or lower jaw quickly follows if a carious 
tooth has permitted the entrance of the drug. 

DIFFERENTIAL DIAGNOSIS: When acute poisoning 
from prosphorus occurs the odor of garlic is pronounced and the 
taste of the same is constantly complained of by the individual. 
Jaundice, hemorrhages from the mucous' membrane and also in 
the fundus of the eye, together with purpuric spots under the 
skin are usually sufficient to make the diagnosis. In addition, 
all early ejected matter either from the mouth or bowels is lumi- 
nous in the dark and the blood and urine contain fat globules. 

Copper Poisoning should not be confounded with phosphorus 
poisoning, but sometimes on account of the jaundice which ap- 
pears in poisoning by copper, the diagnosis may not be made im- 
mediately. 

Acute Yellozu Atrophy of the Liver might be mistaken for poi- 
soning by phosphorus, but in the former there is usually a period 
of prodromes. Violent pain in the esophagus and stomach is not 
complained of in this disease, but is prominent in phosphorus poi- 
soning. The odor of garlic is not present and neither is ejected 
matter luminous in the dark. Percussion over the liver shows the 
area of hepatic dullness to be markedly decreased, while in phos- 
phorus poisoning the liver is greatly enlarged, especially if death 
has not occurred at once. 

HOUSE CONFINEMENT in all cases of acute poisoning 
by phosphorus which terminate fatally, usually require less than 
I day. When death does not occur so quickly house confinement 
of from 2 to 4 or 6 days sometimes follows. If recovery ensues 
house confinement of from i to 2 or 3 weeks is often necessary. 
Chronic cases of phosphorus poisoning do not require any house 
confinement, as treatment in the open air is more beneficial. 

TOTAL DISABILITY in acute cases of poisoning seldom 
lasts over i week. If apparent recovery ensues, total disability 
of from I to 2 or 3 weeks may be present and this in turn is fol- 
lowed by a remission and later another period of disability lasting 
from 2 to 4 or 6 weeks. This is due to fatty degeneration of the 



552 MINERAL POISONS 

different organs of the body and death frequently occurs during 
this period. AA'hen chronic poisoning by phosphorus takes place, 
total disabihty is long and uncertain, lasting weeks and months; 
this time depending on the degree to which the drug has been ab- 
sorbed, the amount of necrosis, the number of operations, if any, 
which are performed for the removal of the dead bone, the phy- 
sical and financial condition of the individual and the method 
of treatment. 

PARTIAL DISABILITY is seldom allowable, for the rea- 
son that accidental cases of poisoning by phosphorus are ex- 
tremely rare. When such a case, however, does arise, this form 
of disability may b^ prolonged, lasting from i to 2 or 4 months 
and sometimes requiring the limit of the poHcy if liability exists. 

EFFECTS : Individuals with a history of having suffered 
from acute phosphorus poisoning are not insurable for any kind 
of a policy until two to three years have elapsed and complete re- 
covery is said to have occurred, and during which time no signs 
or symptoms referable to a degeneration of any of the organs of 
the body appear. Cases of chronic poisoning with necrosis of 
the bones of the jaw are not considered insurable for an}^ kind of 
insurance after poisoning in this form has been suffered. 

POSTMORTEM APPEARANCES when death has been 
jdue to phosphorus are characteristic, unless it occurred almost 
immediately. Jaundice of the skin, the conjunctiva and all the 
organs of the body is seen together with hemorrhagic spots un- 
der the skin and mucous membrane. In addition, this drug pro- 
duces fatty degeneration of the heart, liver and kidneys and when 
phosphorus has been swallowed in the solid form, it is often found 
adhering to the mucous membrane of the stomach or intestines 
or causing a perforation. Evidence of hemorrhages into the peri- 
cardium or pleura and bladder are frequently found and the blood 
is fluid, with a disintegration and destruction of the red cor- 
puscles. The contents of the intestines and sometimes the 
stomach are often found to be luminous in the dark and emit the 
odor of garlic. Evidence of inflammation and degeneration of 
the spinal cord is found in the majority of cases. 

SULPHURIC ACID " 

SYNONYMS: Oil of vitriol; vitriol. 

INFORMATION : Sulphuric acid is one of the strongest 
mineral acids, the most astringent and in the concentrated form 



SULPHURIC ACID 553 

is a heavy liquid, oily in appearance, colorless and odorless when 
pure, but as usually seen in commerce it is of a brownish color. 
This acid is frequently used in the arts and in the manufacture of 
various articles and therefore poisoning either accidental or sui- 
cidal in intent often occurs. Sulphuric acid has a special affinity 
for water, rapidly dehydrating and carbonizing any tissues with 
which it comes in contact. The dilute acid is employed in medi- 
cine and a sufficient quantity will also produce death, although 
the symptoms are not so well marked as when a concentrated so- 
lution is taken. The smallest fatal dose on record for an adult 
is one dram of the concentrated acid, but apparent recovery after 
appropriate treatment has taken place when a much larger amount 
has been swallowed. This acid during its manufacture or when 
transported in lead vessels may be contaminated with lead or ar- 
senic and the possibility of these drugs as impurities should be 
remembered in medico-legal work. 

SIGNS AND SYMPTOMS come on immediately after the 
acid has been swallowed, showing a violent gastro-intestinal in- 
flammation. There is severe burning pain in the mouth, esopha- 
gus and stomach, with nausea and vomiting of highly acid mat- 
ter, which is dark brown in appearance and contains shreds of 
mucous membrane from the parts over which the acid has passed. 
These shreds of membrane are usually white at first but later 
become brown. The blood which is mixed with the vomited mat- 
ter is disintegrated and resembles coffee-grounds. The pulse is 
weak, rapid and irregular, the respirations shallow and feeble, 
the urine scanty, containing albumin and sometimes entirely sup- 
pressed. If some of the acid has been inspired, edema of the glot- 
tis occurs and may be sufficiently marked to cause death at once. 
The stains from this acid on the lips and mucous membrane are 
first white, but rapidlv change to brown or black. 

DIFFERENTIAL DIAGNOSIS between poisoning by sul- 
phuric, nitric or h3^drochloric acid is unimportant, as all three 
acids usually produce death when any quantity has been swal- 
lowed. Sulphuric acid, however, is probably the most corrosive 
of the three. The differential diagnosis between these acids is 
more fullv considered under Nitric and Hydrochloric Acids. 

HOUSE CONFINEMENT following non-fatal doses of 
sulphuric acid depends on the quantity of acid swallowed, its de- 
gree of concentration, the rapidity with which treatment was in- 
stituted and the treatment itself. If recovery follows cases in 
which dilute acid has been swallowed, house confinement lasts 



554 MINERAL POISONS 



4 



from I to 2 weeks. When a small amount of a concentrated solu- 
tion has been taken internally either accidentally or by intent and 
recovery follows, house confinement is usually prolonged, lasting 
from 3 to 6 weeks and frequently from 2 to 3 or 4 months; this 
time depending on the degree of destruction of the mucous mem- 
brane of the stomach and the consequent mal-nutrition which fol- 
lows. Fatal doses of this acid usually produce death within twen- 
ty-four hours, although as above stated, it may not occur until 
months after the drug has been swallowed when it is due to the 
absence of assimilation. 

TOTAL DISABILITY when death occurs from the inges- 
tion of this acid is usually not sufhciently long for a claim for 
weekly indemnity. If death does not follow and recovery ensues, 
total disability may be greatly prolonged on account of the ulcer- 
ation and cicatrices which form wherever the acid has touched 
the- mucous membrane. These causes, together with weakness 
due to impairment of the digestive function of the stomach may 
cause total disability to last from i to 2 or 3 months or more and 
at the end of that time to be followed by death. 

PARTIAL DISABILITY is seldom payable following poi- 
soning by this acid, as when the individual is able to resume the 
occupation, all the duties can be performed. 

EFFECTS : If recovery follows the accidental swallowing 
of dilute sulphuric acid, insurance of all kinds must be denied 
such a person until all danger from the formation of strictures 
has passed This would not be until at least two to three years 
after the ingestion of this acid If the concentrated solution is 
taken internally, such a person would never be considered insur- 
able for any kind of a policy. 

POSTMORTEM APPEARANCES show a violent gastro- 
enteritis, with stains on the skin and mucous membrane wherever 
the acid has touched it. These stains if seen early are white, later 
they become brown or black. The mucous membrane of the 
mouth, throat and stomach is destroyed and separated from its 
base, and if death has occurred early all the coats of the stomach 
are greatly softened so that removal of this organ intact is often 
impossible. Sometimes perforations are found. The contents 
are strongly acid and chemical tests show the presence of sul- 
phuric acid. When death does not occur immediately, some of 
the acid passes into the intestines and sets up a similar inflamma- 
tion. The kidneys show evidence of inflammation and when 
death does not ensue until some months after the acid is swal- 



ACETIC ACID 555 

lowed, they are contracted. The heart is usually, empty and flabby 
and engorgement of the venous system with thick acid blood is 
found. Should the acid come in contact with the clothing the 
spot is characteristic, usually moist with the texture destroyed. 
On white goods this acid produces a black stain and on dark 
goods the stain is first red and then changes to brown. 



PART II 

VEGETABLE POISONS 
ACETIC ACID 

INFORMATION: Poisoning from the swallowing of acetic 
acid is rare and when it occurs the acid is usually taken into the 
mouth by mistake. It is a corrosive poisoning and produces 
changes of the mucous membrane with which it comes in con- 
tact. 

SIGNS AND SYMPTOMS : When acetic acid is taken into 
the mouth and swallowed there follows severe burning pain, with 
vomiting, shock and collapse if a sufficient quantity has been in- 
gested. This acid causes a dirty brown discoloration of the mu- 
cous membrane to appear, and if death does not result the parts 
affected slough and suppuration ensues, leaving a raw, granulat- 
ing surface. 

DIFFERENTIAL DIAGNOSIS between poisoning by any 
of the corrosive acids is unimportant as they all produce practi- 
cally the same signs and symptoms, only varying in the degree 
of severity. Acetic acid as purchased in drug stores is a diluted 
solution, consequently, the effects produced by it are not so 
marked as when the stronger acids are swallowed. 

HOUSE CONFINEMENT is extremely short in cases due 
to poisoning by this acid when a fatal termination occurs: death 
usually following within twenty-four hours. If this does not take 
place, house confinement depends on the amount of acid swal- 
lowed and may last a variable time, from i to 2 weeks in cases 
where only a small quantity has been taken into the mouth and 
little — if an}^ — swallowed, to from 3 to 6 or 8 weeks when a con- 
siderable quantity has been taken into the stomacli but death 
•does not occur. 



556 



VEGETABLE POISONS 



TOTAL DISABILITY of from i to 2 or 3 weeks is de- 
manded in cases where only a small quantity has been ingested. 
Larger amounts produce long periods of disability, sometimes 
lasting from 4 to 6 or 8 weeks or longer, this time being due to- 
the emaciation which results from inability to take or digest 
foods. 

PARTIAL DISABILITY of from 2 to 4 weeks is some- 
times necessary when a reasonably large quantity is taken and 
death does not occur. The payment of partial disability — if the 
policy so provides — is deserved on account of the weakness which 
results. 

EFFECTS : A burn of the mucous membrane from acetic 
acid is followed by an eschar and later contraction of the parts in- 
volved. If the contraction is not serious and does not affect the 
lumen of the esophagus and the acid was swallowed accidentally, 
insurance of all kinds would be safely granted such persons from 
three to six months after complete recover3^ Should permanent 
deformity, such as narrowing of the pharynx or strictures of the 
esophagus result, the risk would be an impaired one and no form 
of policy could be safely issued. 

POSTMORTEM APPEARANCES : In the few fatal cases 
which have reached the postmortem table when death was caused 
by the swallowing of this acid, the mucous membrane of the 
tongue and. esophagus were found to be of a dirty brown color, 
while the mucous membrane of the stomach was discolored and 
scattered over its surface there were small black elevations; these 
being due to the coagulated blood in the mucous membrane and 
underlying tissue. No other changes are reported to have oc- 
curred. 

ACONITE 

SYNONYMS: Aconitum napellus; wolfsbane; monkshood; 
blue rocket. 

INFORMATION: Aconite is probably the most deadly 
poison known, and as the vegetable from, which it is derived is a 
garden plant throughout America, accidental poisoning from eat- 
ing the roots of this plant is not uncommon. These roots resem- 
ble in appearance the roots of the horse-radish plant, but when 
grated the pungent odor of the latter is lacking. If eaten the 
taste is similar to that of horse radish. The strength of the root 
or the preparations made from it varies greatly and depends 011 



ACONITE 557 

the season of the year, the soil from which it is grown and method 
of manufacture; therefore the amount required to produce death 
is uncertain, usually, however, from four to six grains of aconitine 
and from one to two ounces of the tincture are sufficient. 

SIGNS AND SYMPTOMS : When a poisonous dose of this 
drug has been taken internally, it immediately produces tingling 
of the mucous membrane of the mouth, throat and stomach and 
this soon becomes a burning pain with numbness, which gradu- 
ally extends over the body. Dizziness, with muscular relaxation 
rapidly appears and is followed by shallow respirations, feeble 
and rapid pulse and subnormal temperature. Vomiting rarely 
occurs on account of the action of this drug on the nerves of the 
stomach. Dilated pupils are common, while convulsions occa- 
sionally precede the death — which is due to collapse and respira- 
tory failure. 

DIFFERENTIAL DIAGNOSIS: When an unknown poi- 
son has been swallowed and tingling and numbness in the mouth 
and other parts of the body are complained of, together with ab- 
sence of vomiting, it is probable that aconite has been taken in 
one of its various forms. The poison from this plant — which is 
also grown in India — is often used to produce death among the 
natives. 

HOUSE CONFINEMENT in fatal cases of aconite poison- 
ing seldom exists, as this drug generally causes a fatal termina- 
tion in from two to three or four hours; large doses producing 
death within a few minutes. Should recovery follow an acci- 
dental or intentional dose, house confinement rarely lasts over 
2 or 3 days. 

TOTAL DISABILITY does not exist sufficiently long in 
fatal cases to terminate in a claim for weekly indemnity. Should 
death not ensue, total disability in accidental poisoning by aconite 
seldom lasts over 2 to 4 days. 

PARTIAL DISABILITY is not deserved following poison- 
ing by this drug. 

EFFECTS: When aconite has been taken by mistake and 
the danger of a recurrence of the error is eliminated, such a per- 
son is insurable for all kinds of insurance from two to four weeks 
after complete recoverv. 

POSTMORTEM 'appearances are not characteristic 
when death occurs from this drug. \'onous congestion, however, 
lUSually exists, as the death is due to respiratory failure and the 
heart generally stops in diastole. 



558 VEGETABLE POISONS 

BELLADONNA— STRAMONIUM— HYOSCYAMUS 

SYNONYMS: Belladonna (deadly night-shade); stra- 
monium (thorn-apple, Jimson or Jamestown weed); hyoscyamus 
(henbane). 

INFORMATION: Poisoning by belladonna, stramonium 
or hyoscyamus or any of the alkaloids derived fromi these drugs, 
such as atropine, daturine and hyoscyamine are common through- 
out the United States, for the reason that these three plants fre- 
quently grow in gardens. Accidental poisoning commonly re- 
sults from the eating of the berries or roots of these drugs. Death 
does not often follow from hyoscyamine or any of its prepara- 
tions, unless an exceptionally large dose has been swallowed. 

SIGNS AND SYMPTOMS after poisoning by any of the 
three drugs are practically the same. Thirst, with dryness of the 
mouth is always present. This is soon followed by dilation of the 
pupils resulting in indistinct or double vision, dizziness, head- 
ache, a talkative delirium and finally coma and death due to failure 
of the respiratory centers. A rash resembling scarlet fever is 
sometimes produced by atropine. The pulse is rapid and small in 
volume, the respirations are deep and fast and the temperature is 
slightly elevated in the beginning of a case of poisoning, but 
when a fatal termination is about to occur, a subnormal tempera- 
ture precedes the death. All three drugs are eliminated by the 
kidneys; therefore, this secretion gives evidence of the poison. It 
is said that two grains of atropine is the smallest fatal dose of this 
alkaloid on record for an adult. 

DIFFERENTIAL DIAGNOSIS : HydropJwbia may some- 
times be mistaken for poisoning by one of the above drugs, but 
in the former, dilation of the pupils is absent and by securing a 
specimen of urine and dropping some of this into the eyes of an 
animal, the action of these drugs is immediately apparent in caus- 
ing a dilated pupil. 

HOUSE CONFINEMENT is extremely short when poi- 
soning from belladonna, stramonium or hyoscyamus occurs. 
Should death take place as the result of poisoning by any of the 
above drugs, it usually does so within 3 to 6 hours. If a fatal ter- 
mination does not follow, house confinement seldom lasts more 
than I to 2 days. 

TOTAL DISABILITY is not often payable when a fatal ter- 
mination results and if recovery ensues, this form of disability is 
rarely more than from 2 to 3 or 4 days. 



COCAINE 55^ 

PARTIAL DISABILITY is not deserved following poison- 
ing by any of the above drugs. 

EFFECTS: When a poisonous dose has been accidentally 
taken and death does not follow, insurance of all kinds can be 
granted from two to four months after complete recovery. 

POSTMORTEM APPEARANCES are not characteristic 
after poisoning by belladonna, stramonium or hyoscyamus. The 
dilated pupils may or may not persist. If death results from eat- 
ing the berries of the belladonna plant or henbane, a blue or pur- 
ple color of the mucous membrane of the stomach is present. 
Congestion of the vessels of the brain and lungs, with occasion- 
ally red spots along the alimentary canal are found. The alka- 
loids of these drugs are eliminated by the liver and kidneys and 
evidence of the poison can always be found in these organs and 
also in the brain. 

COCAINE 

INFORMATION: Cocaine poisoning is of frequent occur- 
rence among a certain class of individuals. It is often used by 
morphine fiends in an endeavor to correct that habit, but they in 
turn become addicted to the use of cocaine and either symptoms 
of chronic poisoning follow or an overdose is taken accidentally 
or by intent. Deaths due to accidental poisoning by cocaine 
sometimes occur when this drug is given by a physician and this 
is claimed to be due to the instability of the preparations of co- 
caine or eucaine. Overdoses of this drug produce marked stim- 
ulation of the circulatory and respiratory systems and when a 
sufficient quantity has been ingested and causes a fatal termina- 
tion, death is due to respiratory failure, with exhaustion and con- 
vulsions. 

SIGNS AND SYMPTOMS of acute poisoning by cocaine 
resemble those produced by atropine poisoning. ^ The mucous 
membrane of the nose, mouth and throat is dry, impairment of 
vision exists, with sometimes loss of speech, faintness and diilfi- 
culty in swallowing; nausea and vomiting are rare. The respira- 
tions are shallow and feeble, while the pulse which is at first rapid 
and strong soon becomes weak, irregular and intermittent. The 
pupils are widely dilated, the speech is incoherent and talkative 
delirium follows, with convulsions, exhaustion and death. 

Chronic poisoning exists in cocaine fiends and is often as- 
sociated with the habitual use of opium or some of its prepara- 



560 VEGETABLE POISONS 

tions. Such a person shows dilated pupils, sallow skin, marked 
emaciation and languor and complains of insomnia, loss of ambi- 
tion, impaired digestion and weakness and often has hallucina- 
tions and shows enfeeblement of mind. Formication is a common 
symptom of chronic cocaine poisoning in the later stages. 

DIFFERENTIAL DIAGNOSIS: Atropine Poisoning pro- 
duces symptom.s similar to those resulting from an overdose of 
cocaine, but the differential diagnosis can generally be made by 
the history of the case. This drug, however, does not cause death 
as rapidly as cocaine. 

Hydrophobia can usually be differentiated from cocaine poi- 
soning by the history of a bite having been sustained by the in- 
dividual from a rabid animal some time previously and the ab- 
sence of dilated pupils. i| 

Chronic Opiiun Poisoning associated with the habitual use of "' 
cocaine is easily diagnosed; the signs and symptoms following 
the repeated use of either of these drugs being characteristic and 
quickly recognized; the most pronounced are contracted pupils 
in opium poisoning, dilated ones in cocaine, marked emaciation 
in both, with a sallow complexion and a haunted look in each. 
Opium produces chronic constipation which results in diarrhea 
as soon as the drug is stopped, while^ cocaine does not cause this 
condition. Convulsions with dementia follow the constant use 
of either of these drugs. 

HOUSE CONFINEMENT in fatal cases of acute cocaine 
poisoning does not exist, as death almost invariably occurs within 
one-half hour after the drug has been taken in sufficient quantity 
to produce this termination. Chronic cases are not confined to 
the house until after the drug has been taken for some time or 
house confinement exists for the purpose of controlling the co- 
caine fiend. In the former it occurs at intervals of a few days, 
after which the individual is able to go out and around. In the 
latter house confinement is variable, depending on the physical 
condition of the person when treatment is commenced, the 
method of treatment, the surroundings, etc. Usually, however, 
from 2 to 3 weeks confinement in the house are sui^cient, — when 
modern methods demand outdoor exercise. 

TOTAL DISABILITY does not exist in acute cases of co- 
caine poisoning when death occurs. Should such a termination 
follow after this drug has been accidentally swallowed or given 
by a physician, an insurance company, if liable for any indemnity, 
would be held responsible for the specified amount in the policy. 



COLCHICUM 561 

When death does not follow, total disability of from i to 2 or 3 
days is usually ample. Cases of chronic cocaine poisoning should 
not be entitled to this form of disability under an accident or dis- 
ability poHcy. If an accident pohcy alone was in force, total dis- 
ability would not be ahowed, while if a health or disability policy 
existed, totaldisability of from 2 to 4 or 6 weeks might be neces- 
sary in order to secure a release and cancellation of the policy. 

PARTIAL DISABILITY is never deserved fohowing the 
accidental poisoning by this drug, while partial indemnity for 
total disabiHty under a disabihty poHcy might be necessary for 
chronic poisoning. If the poHcy provided this form of indemnity, 
such cases would hardly be entitled to more than from 2 to 4 
weeks under any circumstances. 

EFFECTS : Acute cases of cocaine poisoning which are not 
terminated by death leave no untoward effects and the individual 
is insurable from two to four weeks after recovery ensues under 
any form of policy. Habitual users of cocaine are uninsurable 
for any kind of a policy and if such a history exists in a person 
applying for insurance, an accident, health or life policy would 
hardly be issued by any compan}^, unless five to ten years had 
elapsed after complete cure and no return to the use of the drug 
had occurred. 

POSTMORTEM APPEARANCES in acute cases of co- 
caine poisoning are not characteristic, as death occurs so quickly 
that no pathological changes take place, except perhaps conges- 
tion of the brain, liver and kidneys. When death follows the 
constant use of this drug, the body presents a sallow appearance, 
is markedly emaciated and reveals evidence at numerous points 
where a hypodermic injection has been given. 

COLCHICUM 

SYNONYMS: Meadow Saffron; Colchicum Autumnale. 

INFORMATION: Colchicum is a plant which grows 
throughout the United States in damp meadows. Its poisonous 
properties are due to an alkaloid — colchicine — which it contains. 
Poisoning b}^ this drug is extremely painful and large doses in- 
variably produce a comparatively slow death. From two to four 
drams of the wine of colchicum is almost sure to produce a fatal 
termination, while from one-half to one grain of the alkaloid is 
sufficient for the same purpose. 

SIGNS AND SYMPTOIMS are a burning sensation in the 
36 



562 VEGETABLE POISONS 

mouth, throat and stomach followed by nausea and vomiting, 
with much pain in the abdomen and later purging with tenesmus. 
The stools do not often contain blood, but prostration with mus- 
cular weakness which becomes so pronounced as to result in 
paralysis supervenes. The pulse is rapid and feeble and as death 
approaches collapse due to exhaustion terminates the case. 

HOUSE CONFINEMENT in fatal cases of poisoning by 
this drug seldom lasts over i day; death generally occurring* 
within twenty-four hours. If a fatal termination does not ensue, 
house confinement of from i to 3 days is usually suiftcient for 
recovery. 

TOTAL DISABILITY does not exist when a fatal termina- 
tion takes place. If recovery ensues from 2 to 4 days are gen- 
erally ample for this form of disability. 

PARTIAL DISABILITY does not follow from poisoning 
by colchicum or its alkaloid. 

EFFECTS: If recovery takes place, an individual with a 
history of having suffered from accidental poisoning by this drug 
would be insurable for all forms of insurance from three to six 
weeks after complete recovery. 

POSTMORTEM APPEARANCES: An intense inflamma- 
tion of the mucous membrane of the stomach and intestines ex- 
ists with swelling and sometimes small hemorrhages. The blood 
is usually dark and is slow in coagulating and not uncommonly 
free blood is found in the alimentary canal. In some cases con- 
gestion of the brain, spinal cord and lungs occur. 

IVY POISONING 

SYNONYMS: Poison ivy; poison oak; poison sumac; poi- 
son dogwood; rhus poisoning; dermatitis venenata. 

INFORMATION: Rhus poisoning is the most common 
form of inflammation of the skin due to vegetable irritants and 
follows exposure to vegetables of poisonous origin. It occurs 
most frequently in the spring and fall and usually affects the face, 
hands and forearm, producing an inflammation of the skin of 
these parts, but any part of the body may be involved in the in- 
flammatory process. The genital organs and the inside of the 
thighs often become affected and require confinement to bed. 
Some individuals are especially prone to poisoning by this vine 
and show the characteristic effects after slight exposure, while 
others can handle it with impunity. It is said that the poison ex- 
ists as a non-volatile oil, but it is well known that persons suffer 



IVY POISONING 



563 



from this poison without coming in direct contact with poison 
ivy. DisabiHty from rhus poisoning is generally covered by an 
accident policy under the clause which provides a fractional part 
of the weekly indemnity when disability is ''due to contact with 
poisonous substances.'' If a general disability policy is held by 
a claimant, the full amount of weekly indemnity is payable if the 
claim is covered under the policy. 




Fig'. 121. — Dermatitis \oiumi 
ivy; showing- numerous \esic'! 



.VH>snre 



VHMson 
on1. 



SIGNS AND SYMPTOMS appear within a few hours to 
several days after exposure to a plant which will cause the irrita- 
tion. Burning and itching are first complained of and this is soon 
followed by swelling and redness of the parts involved, with a 
papular eruption ranging in size from . a pinhoad to an eighth 
or quarter of an inch in diameter which cjuickly bocomos vesicu- 



564 



VEGETABLE POISONS 



lar. This condition usually persists for one or two days, when 
the vesicles coalesce and rupture and a dried brownish-yellow 
scab takes the place of the vesicles, — healing following beneath 
this scab, — this latter generally requiring from three to seven 
days and sometimes longer. 

DIFFERENTIAL DIAGNOSIS: Eczema resembles ivy 
poisoning, and is sometimes mistaken for this affection when it 
appears for the hrst time, but individuals who are susceptible to 
rhus poisoning usually make the diagnosis themselves by remem- 
bering exposure to some form of this poison. W^hen eczema 
has been previously suffered, there is a history of a chronic con- 
dition and absence of exposure to pciscn arid the marked inflam- 
matory course as produced by poison ivy is apparent. Eczema 




Fig-. 122. — Dermatitis venenata from exposure' to poison-ivy, following shortly after 
exposure; vesicular and bullous lesions- not an uncomnnon type; hands and forearms 
involved. Ivy-poisoning- several days after exposure. (Stelwagon). 



develops slower and requires a longer time for recovery and is 
not transferable from one part of the body to another by scratch- 
ing as is poison ivy. 

HOUSE CONFINEMENT from poisoning by this vine de- 
pends on the parts of the body affected. AA'hen the hands only 
are involved, house confinement does not often exist, but if the 
face and neck or the genital organs are affected, together with 
the adjacent parts, house confinement varies according to the se- 
verity of the affection and the area of skin involved and may re- 
quire from I to 2 or 3 weeks according to the above conditions. 

TOTAL DISABILITY in preferred risks when the hands 
alone suffer from the poisoning in mild cases, does not often last 
more than from 5 to 7 days. If the hands or fingers are com- 



MUSHROOM POISONING 565 

pletely involved in the poisonous process and the occupation re- 
quires special use of them, total disability generally lasts from i 
to 2 or 3 weeks. Preferred risks whose duties are office and su- 
pervising, are not totally disabled even though the hands are af- 
fected and tied up in bandages. Ordinary risks are totally dis- 
abled from I to 2 weeks when this poison affects the hands only. 
If the face, neck or genital organs are involved, this form of dis- 
ability in all classes of risks lasts from 2 to 3 or 4 weeks, — the 
duration of disability depending on the severity of the poisoning, 
the location, the area and extent of the inflammation and the 
exact duties of the occupation of the individual. 

PARTIAL DISABILITY of i to 2 weeks if allowed by the 
policy is sometimes payable to preferred risks when the hands 
have been involved. Ordinary risks are not entitled to this form 
of disability. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is usually not demanded by any class of risks. Sometimes, 
however, from 3 to 7 days of the form of indemnity are neces- 
sary. 

EFFECTS : All kinds of insurance can be issued one to two 
months after complete recovery to individuals who have suffered 
from this affection, but as they are very prone to have a recur- 
rence and the slightest exposure causes a typical infection to fol- 
low, such persons would not be considered insurable for an acci- 
dent or health policy unless it contained a waiver eliminating in- 
demnity for this affection. 

MUSHROOM POISONING 

INFORMATION: Poisoning from eating mushrooms not 
uncommonly occurs and is due to eating one of two varieties of 
the poisonous form — the amanita muscaria or amanita phalloides. 
Mushroom poisoning generally occurs in the spring or fall when 
iminformed persons collect these fungi from the woods and fields. 

SIGNS AND SYMPTOMS after eating the poisonous form 
do not usually appear until some hours later, when the poison 
manifests itself with sudden and great prostration, accompanied 
by headache, cold perspiration, nuiscniar rolaxaticMi. sometimes 
nausea and vomiting and other times stupor or wild delirium. 
Slight elevation of temperature generally occurs and is accom- 
panied by a rapid, feeble pulse and increasctl respirations. A 



5^^ A'^EGETABLE POISONS 

scanty amount of urine is excreted and this contains albumin and 
oftentimes this secretion is entirely suppressed. Poisoning from, 
muscaria can generally be differentiated from that of phalloides 
by the fact that in the former the lachrymal glands are stimulated 
and an increased flow of tears result, together with profuse per- 
spiration, while in the latter abdominal pain is more marked and 
is accompanied by diarrhea. 

DIFFERENTIAL DIAGNOSIS: Cholera might be mis- 
taken for mushroom poisoning if an epidemic of this disease was 
prevalent. The former, however, almost invariably occurs during 
an epidemic, the signs and S3aiiptoms are more marked and se- 
vere, the period of incubation is three to five days, while mush- 
room poisoning appears within a few hours after the ingestion of 
the poisonous variety and the rice-water stools from mushroom 
poisoning, while closely resembling those of cholera, are not 
typical cholera stools in appearance. The temperature in cholera 
is subnormal, while in mushroom poisoning it is elevated. 

HOUSE CONFINEMENT following poisoning by either 
of the poisonous varieties in which death takes place, requires 
from a few hours to 2 to 4 days. If recovery ensues, house con- 
finement of from 3 to 7 days is generally necessary. 

TOTAL DISABILITY of from 3 to 7 days is usually pay- 
able for mushroom poisoning when the individual is carrying a 
general disability policy. An accident policy does not cover dis- 
ability for mushroom poisoning, for the reason that the fungi are 
eaten intentionally and not accidentalty and although an illness 
may result it is not accidental in origin. Should death take place 
and disability not have lasted seven days there would be no in- 
demnity payable under many general disability policies and no 
death or weekly indemnity should the individual be carrying an 
accident policy. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if allowed by the policy after the termination of house confine- 
ment is never deserved following a case of mushroom poisoning, 
for the reason that when recovery ensues the occupation can be 
resumed shortly after the termination of house confinement. 

EFFECTS : No untoward effects are noticeable after the 
ingestion of poisonous mushrooms, and such a person is insur- 
able for all forms of insurance from two to four weeks after com- 
plete recovery. 

POSTMORTEM APPEARANCES: These fungi are in- 
testinal irritants; therefore, evidence of an inflammation and con- 



NUX VOMICA— STRYCHNINE 567 

gestion of the mucous membrane of the stomach and intestines 
is apparent. In addition they produce effects closely resembling 
those of phosphorus poisoning, the red blood corpuscles are 
broken up or destroyed and this permits an extravasation of 
blood into the tissvies which results in staining. Jaundice of the 
skin and conjunctiva is present and if death does not occur early, 
fatty degeneration of the liver and kidneys is found. Postmor- 
tem rigidity is slow in appearing after mushroom poisoning. 

NUX VOMICA— STRYCHNINE 

INFORMATION: Strychnine in overdoses exerts its chief 
effects on the spinal cord and accidental poisoning from this, drug 
not uncommonly occurs; it is also used by suicides. When nux 
vomica or strychnine is given in a medicinal dose and often re- 
peated, an accumulative action is sometimes seen on account of 
this drug not being eliminated by the system as fast as it is taken 
into it. Strychnine is sometimes used as a poisonous ingredient 
in the preparations of a powder or paste for the destruction of 
small animals, insects, etc., and in such a form produces accidental 
poisoning. Three to five grains of alcoholic extract of nux vom- 
ica and one-half to one grain of the sulphate of strychnine are 
sufficient to produce death. 

SIGNS AND SYMPTOMS following a poisonous dose of 
this drug either come on immediately with instant contraction 
of all the muscles of the body after an excessively large toxic dose 
has been swallowed or they gradually appear in ten to thirty min- 
utes after the drug has been taken into the system. When the 
poison has been swallowed and the symptoms do not follow at 
once, a bitter taste is complained of in the mouth, with a feeling 
of impending sufi'ocation and difficult}^ of breathing. There is 
restlessness, with twitching of the muscles of the arms and legs 
and stiffness of the muscles of the neck. As the poison takes ef- 
fect the characteristic tetanic convulsions begin in the muscles of 
the extremities and extend and involve all the muscles of the 
body. On account of these contractions breathing is interfered 
with and evidence of impaired inspiratory efforts is seen in the 
congestion of the face, staring eyes and the intense agonized ex- 
pression known as "risus sardonicus." The convulsions last from 
one-half to three or five minutes and are followed by a period of 
relaxation; during this time the breathing is normal and appar- 
ently nothing is wrong with the individual. The pupils are 



568 VEGETABLE POISONS 






usually dilated during the convulsions and contracted in the in- 
terval. The duration of the intervals may be from one to two 
minutes to one-half hour or more, according to the amount of 
poison taken into the system and its effects. The convulsions 
are easily excited by a breath of air, sHght movement of the bed 
or attempts at swallowing. Great thirst exists and spasms are 
produced by the slightest attempts to quench it. The blood is 
not sufficiently aerated on account of the convulsions, but the 
mind is clear until a fatal termination ensues and this is usually 
due to exhaustion following repeated convulsions or from as- 
phyxiation. Death from poisoning by nux vomica or strychnine 
generally occurs within one-half to two hours. 

DIFFERENTIAL DIAGNOSIS: Tetanus may sometimes 
he mistaken for strychnine poisoning, but in the former there is 
obtainable a history of a wound which was inflicted some time 
previously. In tetanus the s^^mptoms are gradual in onset and 
do not become severe until several hours or more after the com- 
mencement, while in fatal cases of strychnine poisoning death 
has taken place before the symptoms of tetanus would have been 
well developed. Tetanus produces clonic spasms of the muscles 
and those of the face and neck are usually early affected, while 
in strychnine poisoning the spasms are tetanic in character and 
the muscles of the neck and face are generally the last ones to 
be involved. In tetanus the mind is cloudy or consciousness is 
completely lost, while in strychnine poisoning the mind is al- 
ways clear until death occurs. 

HOUSE CONFINEMENT in fatal cases of poisoning from 
nux vomica or strychnine does not last sufficiently long for a 
claim for weekly indemnity, as death almost invariably takes place 
under twelve hours. When recovery follows a large dose of this 
drug, house confinement of from 2 to 4 or 6 days may sometimes 
be required, on account of the energetic treatment that would be 
necessary to institute in a case of this poisoning and the exhaus- 
tion which would follow. 

TOTAL DISABILITY is not payable for fatal cases of 
strychnine poisoning. If recovery follows the ingestion of a 
large dose of nux vomica or strychnine, total disability of from 
3 to 7 days usually results. 

PARTIAL DISABILITY or PARTIAL INDEMNITY 
FOR TOTAL DISABILITY is not payable following poisoning 
by this drug. 

EFFECTS : Individuals having suffered from accidental 



OPIUM AND MORPHINE 569 

poisoning by nux vomica or strychnine which is followed by re- 
covery, are insurable for all forms of insurance three to six weeks 
later, provided the Hability of a recurrence of accidental poison- 
ing is eliminated. 

POSTMORTEM APPEARANCES: When death follows 
strychnine poisoning, the body may become rigid at once or 
death may occur during the relaxation of the muscles and be fol- 
lowed in five to ten minutes by postmortem rigidity which is very 
pronounced. The hands are generally closed and tightly clenched, 
while the foot is curved downward, causing a well marked arch to 
be formed on the plantar surface; sometimes opisthotonos is 
present. On opening the body, the blood is found to be dark and 
liquid and the external surface of the stomach is often highly 
congested. The heart is generally contracted, but occasionally 
the right side is distended and filled with black, fluid blood. If 
any urine is in the bladder it shows albumin and also contains 
strychnine. When the brain and spinal cord are opened they are 
found congested and an over secretion of serous fluid is present. 

OPIUM AND MORPHINE 

INFORMATION : Opium is a dried juice or milky exudate 
which appears on the surface of the unripe capsules of white 
poppy or Papaver Somniferum. This plant is a native of Asia, 
but is now grown in other parts of the world. The drug derives 
its medicinal properties from its alkaloid — morphine — although 
a number of other alkaloids are found in crude opium. Morphine 
is most frequently employed in medicine and is also used to pro- 
duce poisonous effects whether taken intentionally or by mistake. 
The strength of opium varies; consequently, the different tinc- 
tures made from this drug are not always of the same strength. 
Old tinctures in which the alcohol has evaporated, are much 
stronger than recent ones or preparations of the drug which are 
sold in some drug stores without prescriptions. Opium and mor- 
phine produce practically the same signs and symptoms; opium, 
however, acting less quickly than does morphine. The latter i^ 
a stronger hypnotic than the former, but more frequently pro- 
duces pruritus and cutaneous eruptions. It also causes loss de- 
rangement to the stomach, it is not as constipating as opium and 
does not as commonly produce retention of urine as the original 
drug. The fatal dose of opium and morphine varies according to 
the age and physical condition of the individual and whether the 



570 VEGETABLE POISONS 

drug has been habitually used or not. Two drams are said to be 
the smallest quantity of tincture of opium that has produced a 
fatal termination. The average fatal dose of the tincture, how- 
ever, being one-half ounce. Four grains of crude opium — equal 
to two and one-half grains of the extract — have produced death 
when taken at one time. One grain of morphine is the average 
fatal dose to an adult who is unaccustomed to its use. 

SIGNS AND SYMPTOMS from poisoning by opium may 
not appear until one-half to one hour after the drug has been 
swallowed, while morphine if given in an overdose hypodermi- 
cally, may produce symptoms of poisoning within a few minutes. 
Opium or morphine when swallowed in toxic doses produces a 
short stage of cerebral excitement and this is followed by drowsi- 
ness, which soon becomes an intense desire for sleep. Before 
deep sleep ensues there is dizziness, headache and muscular re- 
laxation. In the beginning, the individual can be aroused by 
shouting in the ear, shaking and other means, but as the drug 
becomes more effective, total insensibility ensues, the breathing 
becomes loud and jerky, the pulse — which at first was full and 
strong — becomes weak and irregular, both pupils are strongly 
contracted, usually to pin points and refuse to react to light. Just 
before death occurs, one or both pupils dilate. All the secretions 
of the body are diminished, with the exception of perspiration 
which usually appears on a cold skin, causing a clammy feeling. 
In fatal cases edema of the lungs is present, together with mus- 
cular twitchings and sometimes bloody diarrhea. When death 
follows it is due to respiratory failure, although sometimes pa- 
ralysis of the heart is the cause. 

Chronic poisoning due to the habitual use of opium or mor- 
phine produces symptoms which are easily referable to this drug. 
There is a general cachectic appearance, with sinking in of the tis- 
sues around the eyes, a dark line beneath them, sallow com- 
plexion, loss of ambition and strength, impaired digestion, consti- 
pation, insomnia, anorexia, together with mental depression and 
oftentimes impairment. The pupils are contracted while the in- 
dividual is under the effects of the drug and dilate as soon as the 
effects wear off. The majority of morphine fiends take this drug 
hypodermically; therefore, the arms and legs show the scars of 
multiple punctures. Habitual users of opium or morphine seem 
unable to tell the truth at any time, even though it serves better 
than a falsehood. 

DIFFERENTIAL DIAGNOSIS: Coma mav be due to a 



OXALIC ACID 571 

number of causes, its diagnosis is highly important -and is con- 
sidered under Concussion of the Brain. 

HOUSE CONFINEMENT following poisoning by opium 
or morphine in which recovery takes place rarely lasts more than 
from 2 to 4 days. 

TOTAL DISABILITY following acute opium or morphine 
poisoning seldom lasts more than from 3 to 5 days. Habitual 
users of this drug are totally disabled i to 2 days only and these 
periods of disability occur at irregular intervals. Such persons, 
however, would not be covered by an insurance policy for indem- 
nity. When death follows the taking of large doses of this drug, 
it usually occurs within twelve hours and in such cases no weekly 
indemnity would be payable. 

PARTIAL DISABILITY or PARTIAL INDEMNITY 
FOR TOTAL DISABILITY is not payable in any case follow- 
ing the taking of this drug. 

EFFECTS: Individuals having suffered from acute opium 
poisoning which was accidental in origin are insurable for all kinds 
of insurance from three to six weeks after complete recovery, 
provided the opportunity for the accidental taking of the drug 
is eliminated. Opium or morphine fiends are uninsurable for any 
kind of insurance at any time. 

POSTMORTEM APPEARANCES are not characteristic 
and this is especially true if death occurs early. If the tincture 
of opium has been swallowed an odor is sometimes perceptible 
on opening the stomach, but when morphine has been taken no 
odor is apparent. If death has not ensued until six to eight hours 
after the ingestion of this drug, the vessels of the brain are usually 
engorged and there is an effusion of serum into the ventricles 
. and at the base of the brain. The lungs generally show edema 
and are filled with blood, while the right side of the heart is dis- 
tended with dark fluid or clotted blood. The bladder is not un- 
commonly found to contain a considerable quantity of urine and 
this secretion shows the presence of the poison. Y/hen death has 
occurred from an overdose in a morphine fiend, the body is found 
to be emaciated and evidence of multiple punctures of the skin 
of the forearms and legs by the hypodermic needle is apparent. 

OXALIC ACID 

SYNONYM: Acid of sugar. 

INFORMATION: Oxalic acid is frequently used in at- 



572 VEGETABLE POISONS 

tempts at suicide because it is cheap and easily purchased. It 
is also often taken accidentally, this acid resembling Epsom salts 
and when dissolved in water the resulting mixture is colorless 
and has an acid taste. When swallowed in the concentrated form- 
death quickly follows and if taken diluted, its action is mainly on 
the nervous system and a fatal termination does not often occur. 
A dram and a half is the average fatal dose when concentrated. 

Acid potassium oxalate (salt of sorrel, essential salt of 
lemons) when swallowed produces practically the same signs and 
symptoms as does oxalic acid; this being due to the latter acid 
which is contained in the former. 

SIGNS AND SYMPTOMS : When a large concentrated 
dose is swallowed it immediately causes a burning pain in the 
mouth, throat and stomach to be followed at once by retching and 



^ 



^ ^ 

% 



u o 

Si 

Fig. 123. — Various forms of calcium, oxalate crystals. (Ogden). 

vomiting; the vomited matter consisting of the contents of the 
stomach, with a strongly acid reaction and containing disinte- 
grated blood. The color of the vomit is dark brown or black. 
Occasionally vomiting does not occur. Severe pain is complained 
of in the abdomen and this is increased by pressure. Collapse 
with its attendant signs and symptoms ensues and death rapidly 
follows; usually occurring within one-half hour. Smaher doses 
when taken diluted act on the nerve centers, producing cramps 
and numbness of the extremities, nervousness and sometimes de- 
lirium. In addition there is thirst, swelling of the tongue and oc- 
casionally salivation. The urine following the ingestion of this 
poison in the concentrated or diluted form shows an enormous 
quantity of oxalate crystals. It is greatly diminished in quantity 
and sometimes entirely suppressed. 

DIFFERENTIAL DIAGNOSIS between poisoning by ox 



OXALIC ACID 573 

alic acid and potassium oxalate is difficult and unimportant; the 
signs and symptoms being practically the same in cases of poison- 
ing by either drug. Oxalic acid causes a scalded appearance of 
the mucous membrane of the mouth and throat and later these 
surfaces are covered by dark brown mucus. Increased quantities 
of oxalic acid in the form of oxalate crystals are early found in 
the urine. A diagnostic point of poisoning by oxalic acid is sud- 
den dullness and apathetic condition of the individual following 
signs of severe gastro-intestinal irritation and death within one- 
half to an hour. 

HOUSE CONFINEMENT in fatal cases when a concen- 
trated -solution of this drug has been swallowed seldom exists, 
as death takes place almost immediatel}^ When the acid is taken 
in a diluted form and death ensues, house confinement generally 
lasts from i to 3 or 4 days. If recovery follows this form of poi- 
soning^ convalescence is slow and protracted and confinement to 
the house lasts from 2 to 3 or 4 weeks; this time depending on a 
number of conditions; namely, the amount of acid taken, whether 
concentrated or diluted, the state of the stomach at the time the 
acid is swallowed, if empty or containing food, the physical con- 
dition of the individual and the rapidity with which treatment is 
instituted after the poison has been taken. 

TOTAL DISABILITY in cases which are not fatal within 
one-half to an hour, but which finally terminate in such a man- 
ner, seldom require more than from 2 to 4 or 5 days. When re- 
covery takes place total disability of from 2 to 4 or 6 weeks is 
often necessary after the ingestion of this acid. 

PARTIAL DISABILITY when oxalic acid has been taken 
accidentally seldom lasts more than i to 2 weeks, for the reason 
that when the occupation is resumed, usually all the duties can 
be undertaken. 

EFFECTS : Oxalic acid being a corrosive, vegetable acid, 
it causes destruction of tissue when swallowed and is followed by 
cicatrices. Individuals, therefore, who have swallowed this acid 
accidentall}^ are uninsurable for all kinds of insurance until two to 
three years have elapsed and no evidence of stricture of the eso- 
phagus exists. 

POSTMORTEM APPEARANCES vary according to the 
amount of acid swallowed. Concentrated doses result in whiten- 
ing of the mucous membrane of the month, throat and stomach 
and this corroded part soon becomes covered witli brownish nui- 
cus. The parts touched l\v the acid are sc->fi or brittle and easily 



574 MISCELLANEOUS POISONS 

removed and beneath the destroyed surfaces of mucous mem- 
brane is an area of inflammation. The contents of the stomach 
are acid, often being fluid and dark in color and containing much 
disintegrated blood. Perforation of the stomach sometimes oc- 
curs and removal of this organ is usually difficult on account of 
the action of the acid. When death has not ensued at once the 
small and large intestines show evidence of inflammation, and the 
kidneys also in such cases are inflamed, while the urine contains 
large quantities of calcium oxalate crystals. The blood is acid 
and usually dark and fluid, although it may be thickened. 



PART III 

MISCELLANEOUS POISONS 
ACETANILID— ANTIPYRIN— PHENACETIN 

INFORMATION: Drugs derived from the destructive dis- 
tillation of coal tar are now very frequently used in medicine and 
the above are among the most prominent. They all possess com- 
mon properties and the description of one sufflces for all. The 
frequent use of headache powders and effervescent drugs for the 
relief of various pains and constipation, often result in poisoning 
and the signs and symptoms thus produced are due to some coal 
tar product which is contained in the headache or effervescent 
powder and generally this drug in headache powders is acetanilid 
— as it is the cheapest. Chronic poisoning by coal tar products 
in the shape of so-called headache powders is often undiagnosed,' 
although the person suffers with ill health from no apparent 
reason. These drugs exert their most pronounced action on the 
blood, reducing its alkalinity and power of carrying oxygen to 
the tissues and finally ending in a disintegration of the red blood 
corpuscles. A fatal dose of any of these drugs is variable; as 
small as five to ten grains having produced death, while again 
one dram or more may be taken and a fatal termination not ensue. 

SIGNS AND SYMPTOMS after a toxic dose of any of the 
coal tar derivatives usually show themselves within fifteen min- 
utes to one hour after the ingestion of the drug. Chilliness is 
complained of and is followed by cyanosis of the face, with blue 
lips and anxious expression. A cold perspiration appears on the 



ACETANILID— ANTIPYRIN— PHENACETIN 575 

forehead and gradually extends and involves the whole body. The 
pulse is slow, soft and compressible and finally becomes weak and 
irregular, the respirations are shallow and sometimes nausea and 
vomiting occur. General anesthesia with loss of reflex action 
and motor and sensory paralysis is seen when large poisonous 
doses are taken. When death takes place it is due to respiratory 
failure. 

Chronic poisoning resulting from the habitual use of these 
drugs unauthorized by a physician results in a general deteriora- 
tion of the health, with no prominent signs and symptoms that 
indicate any disease to be existing. There is great mental irri- 
tability, restlessness, impaired digestion and on account of the 
destruction of the red blood corpuscles, a sallow complexion re- 
sults and the heart action is irritable and irregular. The urine is 
dark in color and often contains albumin. 

DIFFERENTIAL DIAGNOSIS between poisoning by 
acetanilid, antipyrin or phenacatin is unimportant and practically 
impossible; the treatment is the same in all cases. 

HOUSE CONFINEMENT in acute poisoning by coal tar 
derivatives, when recovery takes place, seldom lasts more than 
from 3 to 7 days. If a fatal termination occurs it usually does so 
within twenty-four hours and therefore no claim for weekly in- 
demnity under an accident policy is payable if the drug was acci- 
dentally taken. 

TOTAL DISABILITY when death ensues, does not last 
long enough to constitute a claim for weekly indemnity and if an 
individual carrying an accident policy voluntarily takes any of 
these drugs or headache powders and death results, an insurance 
company is not liable for an accidental death claim. If recovery- 
follows the taking of a toxic dose of these drugs, total disability 
of I to 2 weeks results, but this time is not covered by an accident 
policy. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment may sometimes be demanded and if payable, i week is 
usually ample. 
, EFFECTS: When an individual has suffered from acute 

I poisoning by one of the coal tar products or from a condition due 
to the habitual use of these drugs, insurance of all kinds must be 
denied such a person, until three to six months after complete 
recovery has ensued and is shown to exist by a medical examina- 
tion. 



576 MISCELLANEOUS POISONS 

POSTMORTEM APPEARANCES after acute poisoning 
by acetanilid, antipyrin or phenacetin show the blood to be dark 
in color and the lungs filled with fluid-unaerated blood. The 
heart is flabby and the kidneys are congested and filled with disin- 
tegrated red blood corpuscles. The urine is very dark and also 
contains broken down red blood corpuscles. Death from the ha- 
bitual use of this drug shows the body emaciated and in addition 
to the above, fatt}- degeneration of all the organs is present. 
These drugs are eliminated by the kidneys and proper tests reveal 
the presence of the chemical product which is formed when these 
coal tar products are broken up in the body. 

METHYL ALCOHOL 

SYNONYMS: AA'ood alcohol: Wood, Columbian or Co- 
lonial spirit. 

INFORAL\TION : A\'ood alcohol is now so extensively 
used that accidental poisoning from swallowing this liquid not 
uncommonly occurs, this form of alcohol being mistaken for ethyl 
alcohol. Poisoning may also result when methyl alcohol is used 
in the preparations of certaiii alcoholic extracts, which are sold at 
reduced prices. This form of alcohol is a dangerous poison and 
in toxic doses — which are not fatal — exerts its most pronounced 
effects on the optic nerves resulting in partial or complete blind- 
ness. The inhalation of methyl alcohol in a closed room is said 
to produce signs and symptoms of poisoning. The amount of a 
fatal dose of wood alcohol varies: five drams having caused total 
blindness in a reported case, while one to three ounces may be 
sufficient to cause death. 

SIGNS AND SYMPTOMS after a fatal dose has been swal- 
lowed are headache, vertigo, muscular weakness, with nausea and 
vomiting. This soon ends in coma and death within eight to 
twenty-four hours and sometimes earlier. AMien a poisonous 
dose has been ingested and a fatal termination does not occur, in- 
flammation of the optic nerve results. There is tenderness of 
the eyebaU and movement causes pain, the pupils are dilated and 
do not react to light and the sense of color perception is dimin- 
ished in the early stages. As the effect of the poison becomes 
more pronounced an optic neuritis follows, with exudation into 
the retina and gradually loss of vision. This may persist for sev- 
eral days or even weeks and be followed by blindness and this 
in turn by an improvement, in which some sight gradually re- 



METHYL ALCOHOL 577 

turns, but usually this disappears and total and irrecoverable loss 
of vision results. Atrophy of the optic nerve is present at this 
time. When a non-fatal dose is swallowed, nausea and vomiting, 
with headache, dizziness and muscular relaxation may not ensue 
until one to three days later, and at this time be accompanied with 
the above described changes in the eyes. 

HOUSE CONFINEMENT following rapidly fatal cases of 
methyl alcohol poisoning does not usually last longer than 
twelve to twenty-four hours, when a fatal termination occurs. If 
recovery ensues house confinement is variable and uncertain; 
sometimes requiring only from 3 to 7 days and other times per- 
sisting for from 2 to 3 or 6 weeks. When house confinement is 
prolonged it is usually due to the changes which occur in the eyes 
and which necessitate confinement to a darkened room in an en- 
deavor to preserve the sight. 

TOTAL DISABILITY following accidental poisoning by 
methyl alcohol is not present when a fatal termination rapidly 
takes place. If death does not ensue after a poisonous dose has 
been swallowed, total disability may last from i or 2 to 3 or 6 
weeks. Sometimes on account of complete loss of sight total dis- 
ability is permanent. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
when house confinement is not required by the policy is uncer- 
tain and may last only from i to 2 or 3 weeks, while again the 
limit of the policy may be required before this form of disability 
is ended. 

EFFECTS : In poisoning by wood alcohol which is followed 
by complete recovery and no impairment of vision, an insurance 
company would issue all forms of insurance from three to six 
weeks after complete recovery. If partial or complete loss 01 
sight followed, it is questionable if any kind of a policy would bo 
granted such a person. 

POSTMORTEM APPEARANCES following an early 
death after the ingestion of wood alcohol show an acute conges- 
tion of the alimentary canal, the brain and spinal cord. The urine 
frequently contains albumin and if death has not occurred im- 
mediately, changes in the eye are shown by a microscopic exam- 
ination. When death takes place some days or weeks after tho 
ingestion of the poison, fatty degeneration of the organs of the 
body is seen, together with changes in the eyeball and atrophy of 
the optic nerves. 



578 MISCELLANEOUS POISONS 

AAIMONIA 

SYNONYMS: Liquid ammonia is known as volatile alkali; 
hartshorn; ammonia; ammonia water. 

INFORMATION: Ammonia is a colorless pungent gas and 
may produce death in this form by inhalation. In commerce this 
gas is dissolved in water and its strength varies according to the 
percentage of gas contained in the Hquid. In this form it causes 
disability and death when swallowed and sometimes produces a 
fatal termination when a sufficient quantity of the gas is inhaled 
while a solution of it is being swallowed. Death from the inhala- 
tion of fumes of ammonia is usually accidental in origin and oc- 
curs to individuals employed where this gas is manufactured or 
used. Liquid ammonia being colorless, is sometimes swallowed 
by mistake and if enough is taken death results. When am- 
monia gas is inhaled death ensues at once, but if the gas dissolved 
in water is swallowed, the usual time required for a fatal termina- 
tion is twelve to fifteen hours. 

SIGNS AND SYMPTOMS after the inhalation of undiluted 
ammonia gas follow immediately. There is dyspnea, violent pain 
in the air passages of the head and in the lungs, with edema and 
spasm of the glottis causing almost instant death by suffocation. 
When the gas is more or less diluted with air and inhaled, the 
same symptoms supervene but are less marked, and in many cases 
after several hours pneumonia develops. The symptoms of poi- 
soning by liquid ammonia which is swallowed, depend on the 
amount of gas dissolved in the water. Strong solutions produce 
a severe burning pain in the mouth, throat and stomach which 
soon extends and involves the abdomen and is increased by pres- 
sure. Loss of voice, with profuse salivation, difficulty in swallow- 
ing and swelling of the tongue occur. Nausea supervenes and is 
followed by vomiting of first the contents of the stomach — which 
appear soapy in character — and this is soon followed by the ejec- 
tion of shreds of mucous membrane and blood stained mucus and 
violent bloody purging. The urine is diminished in. quantity, be- 
comes strongly alkaline and contains blood and albumin. When 
these symptoms are not sufficiently severe to cause death, pneu- 
monia may develop within a few hours after the poison has been 
swallowed, and in such cases the typical signs and symptoms of 
this disease develop. 

HOUSE CONFINEMENT does not exist when death fol- 
lows the inhalation of ammo.nia gas. If this poison is swallowed 



CANTHARIDES 579 

in the liquid form and death takes place, it usually does so within 
twenty-four hours. Should recovery ensue after a more or less 
concentrated solution of the gas in water is taken into the 
stomach, house confinement depends on the degree of concentra- 
tion and the subsequent destruction of tissue. Usually, however, 
I to 2 weeks are sufficient. 

TOTAL DISABILITY does not follow when death occurs 
after ammonia has been inhaled or swallowed in the concentrated 
form. When recovery ensues, the length of total disability is var- 
iable and depends on the degree and area of tissue destroyed and 
the resulting impairment of digestion. The majority of cases 
usually demand from 2 to 6 weeks. 

PARTIAL DISABILITY of from 2 to 4 or 6 weeks is some- 
times payable to individuals who have accidentally swallowed a 
strong solution of ammonia. 

EFFECTS : When a concentrated solution of ammonia has 
been taken and is followed by recovery, such a person would be 
uninsurable for any kind of a poHcy until one to three years had 
elapsed after the drug was swallowed; this being due to the fact 
that destruction of the mucous membrane occurs and cicatrices 
which result may become so contracted that nutrition is badly 
impaired. 

POSTMORTEM APPEARANCES when death follows the 
inhalation of fumes of ammonia are not characteristic. If the 
body is opened early enough, ammonia is detected by the odor. 
The blood is markedly alkaline in reaction and evidence of a vio- 
lent inflammation involving the glottis and lungs is seen. If the 
drug is swallowed the odor may be detected in the stomach, 
which, with the mouth and throat shows an intense inflammation 
with destruction of the mucous membrane and softening of the 
parts involved. Usually extravasation ,of blood occurs into the 
stomach and frequently a false membrane exists in the esophagus. 
If any urine remains in the bladder it contains blood and albumin, 
is darker in color than normal and extremely alkaline in reaction. 

CANTHARIDES 

SYNONYM: Spanish flies. 

INFORMATION: Cantharides is a well known and ex- 
tremely powerful irritant drug, which is often given in overdoses 
by uninformed persons to produce an effect and this is especially 
true when the poisoning occiu's in women. Cantharides is gen- 



580 MISCELLANEOUS POISONS 

erally employed in the powder form by ignorant persons, although 
the tincture is sometimes used. From one-half to one dram of 
the powdered insects and from one to two ounces of the tincture 
are usually sufficient to produce a fatal termination. Smaller 
doses will cause death when the kidneys are diseased. 

SIGNS AND SYMPTOMS after a toxic dose of Spanish fly 
has been taken show themselves in one to three hours by a feeling 
of faintness with dizziness, a burning, stinging sensation in the 
mouth, throat and stomach, with nausea and vomiting of glairy 
mucus which is sometimes blood stained. The pain — which is 
first complained of in the stomach — soon extends and involves 
the entire abdomen and is accompanied b}^ pain in the loins, se- 
vere strangury, priapism and the passage of bloody urine. Purg- 
ing generally takes place when this form of poison is swallowed. 
The stools are first mucus in character, then fibrinous and finally 
very numerous but scanty in amount and bloody. Salivation 
often follows with swelling of the salivary glands and not uncom- 
monly blisters are found in the mouth. Respirations are in- 
creased in number and are shallow, while the pulse is rapid and 
strong in the early stages, but gradually becomes weaker. Se- 
vere thirst is always a prominent symptom of this poisoning and 
frequently a fatal termination is preceded by convulsions, dehrium 
and coma. When poisoning from cantharides occurs in the male, 
sex, violent erotic excitement follows, showing itself by heat and! 
swelling in the penis, with priapism and frequent emissions of] 

seminal fluid. 

DIFFERENTIAL DIAGNOSIS: When poisoning by 
Spanish fly has occurred by the powdered insects being swal- 
lowed accidentally or taken in an overdose by intent, the vomited 
matter contains the shiny, golden-colored particles of the wings 
which are apparent to the naked eye in the majority of cases, and 
if not, the microscope will reveal the smaller particles. If the 
tincture has been taken the acute violent inflammation of the gen- 
ital organs and the desire for sexual intercourse will usually serve 
to show the kind of poison producing the disability. 

HOUSE CONFINEMENT following a poisonous dose of 
these insects if death does not ensue, usually lasts from i to 2 
weeks. When death occurs, house confinement does not often 
require more than from i to 3 or 5 days and this time is not suffi- 
ciently long for a claim under a disability policy when the policy 
does not pay indemnity for less than one week. Sometimes, how- 



i 



CANTHARIDES 581 

ever, death does not occur early and house confinement may last 
from 2 to 3 weeks. 

TOTAL DISABILITY following a fatal dose of Spanish fly 
does not often require more than from 2 to 5 days, although a 
fatal termination may be delayed and total disability of from i to 
3 weeks exist before death occurs. If recovery takes place total 
disability is uncertain and depends on the physical condition oi 
the individual and especially the condition of the kidneys, whether 
diseased or not, the quantity of poison swallowed and the rapidity 
with which treatment is instituted. Usually, however, from i to 
2 or 3 weeks are ample. In cases with diseased kidneys, this 
form of disability may be greatly increased, lasting from 3 to 6 
weeks and sometimes longer. 

PARTIAL DISABILITY is sometimes payable when the 
poison has been accidentally swallowed by an individual whose 
kidneys are impaired and death does not result. Under such con- 
ditions from 2 to 4 or 6 weeks of this form of disability following 
a period of total may be necessary. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
is sometimes required when this drug has been voluntarily taken 
in an overdose and in such cases if house confinement is not neces- 
sary for this form of indemnity, from 2 to 4 or 6 weeks may be 
payable before complete recovery ensues. 

EFFECTS: On account of Spanish fiy exerting its most 
pronounced effects on the kidneys and sexual organs, an indi- 
vidual having suffered from a toxic dose which did not result 
fatally, would be uninsurable for life or health insurance until at 
least three to six months had elapsed without any signs or symp- 
toms referable to the poisoning and a medical examination had 
shown the secretion of the kidneys to be normal. Accident in- 
surance in such cases can generally be issued as soon as complete 
recovery ensues. 

POSTMORTEM APPEARANCES: These insects when 
swallowed produce a gastro-intestinal irritation and therefore evi- 
dence of inflammation in the mouth, throat, stomach and intes- 
tines is apparent. When death takes place from this cause, blist- 
ers and sometimes ulcers of the stomach and intestines are pres- 
ent. The genital organs and kidneys are congested and inflamed, 
the ureters show evidence of the same condition, together with 
the bladder which is contracted. Sometimes ulcerations exist in 
the bladder and urethra. 



582 MISCELLANEOUS POISONS 

CAUSTIC ALKALIES 

SYNONYMS: Poisoning by fixed alkalies; poisoning by 
concentrated lye. 

INFORMATION : Poisoning from the swallowing of caus- 
tic alkalies such as potassium, sodium or ammonium hydroxid not 
uncommonly occurs, but it is usually more frequent among chil- 
dren, when lye in a more or less concentrated form is swallowed 
by mistake. Potassium hydroxid exerts a more depressing ac- 
tion on the heart than does sodium h3^droxid. All caustic alkahes 
are extremely corrosive in eft'ect and destroy the tissues with 
which they come in contact, but in a dift'erent manner than do 
the corrosive acids. Caustic alkalies are very deliquescent and 
quickly unite with the fats and albuminoids of the tissues forming 
soluble soaps, with the subsequent destruction of the tissues. 
From two to four ounces of liquor potassse or sodse are sufficient 
to produce death in adults, while a much larger quantity of con- 
centrated lye is necessary in the same class. 

SIGNS AND SYMPTOMS come on immediately after 
these poisons have been swallowed and consist of an exceedingly 
severe burning pain in the mouth, throat and stomach with a 
soapy taste, cold skin and clammy perspiration. Pain in the 
stom.ach soon extends and involves the abdomen which becomes 
very tender to the touch. Nausea and vomiting occur early, the 
latter consisting of the contents of the stomach which appear 
frothy and are tinged with more or less blood. The respirations 
are shallow and rapid, the pulse feeble and irregular while the 
urine is dark, scanty and sometimes entirely suppressed. All the 
symptoms of profound collapse ensue when death takes place or 
a rernission occurs and a fatal termination does not follow until 
later. 

DIFFERENTIAL DIAGNOSIS between the corrosive 
acids and caustic alkalies is very important. When a corrosive 
acid has been taken its particular stain of the mouth or clothing 
is usually apparent, while with the caustic alkalies no stain exists. 
The vomited matter in acid poisoning is always extremely acid, 
but when a caustic alkali has been swallowed the opposite is true. 
Both forms of poisoning destroy the mucous membrane, but in 
acid poisoning the shreds of membrane which are cast off gen- 
erally show the particular stain of the acid that causes the de- 
struction, while the mucous membrane which is detached owing 
to a caustic alkali beins: swallowed, does not show this discolora- 



CAUSTIC ALKALIES 583 

tion. The vomit due to a caustic alkali is always soapy and frothy 
in character and this is not the case when a strong acid has been 
taken into the stomach. 

HOUSE CONFINEMENT when a caustic alkaU has been 
swallowed does not last more than i to 2 days if death ensues. 
Should recovery follow, confinement to the bed and house of 
from I to 2 or 3 weeks is often necessary; this time depending 
on the degree of concentration of the solution swallowed and the 
area of tissue destroyed. 

TOTAL DISABILITY following the swallowing of caustic 
alkalies in which death occurs, does not usually last long enough 
to constitute a claim for weekly indemnity under a disabiHty pol- 
icy. When death does not take place, total disability is variable 
and depends on the strength of the solution, the area of tissue de- 
stroyed, the physical condition of the individual and the rapidity 
with which treatment is begun after the swallowing of the poison. 
If a concentrated solution is diluted either before or immediately 
after being swallowed, total disability is not long, sometimes only 
lasting from i to 2 or 3 weeks. 

PARTIAL DISABILITY of from i to 3 weeks is sometimes 
payable to individuals who have swallowed a solution of caustic 
alkali by mistake. 

EFFECTS : When a history exists of a concentrated solu- 
tion of any caustic alkali having been swallowed and followed by 
recovery, such a person would be uninsurable for life or health in- 
surance until one to three years after the date of accident; this 
being due to the probability of the formation of strictures and 
also the destruction of the peptic glands of the stomach. Acci- 
dent insurance in such cases could be safely issued from three to 
six months after apparent complete recoverv. 

POSTMORTEM APPEARANCES: After a death due to 
the concentrated solution of lye, there is noticed a violent inflam- 
mation of the mucous membrane of the mouth, throat and 
stomach. Wherever the caustic has touched the nutcous mem- 
brane it is usually destroyed and discarded and in its place is a 
raw surface. Caustic alkalies produce the most pronounced ef- 
fect on the lower part of the esophagus, sometimes causing a 
perforation at this point. The nuicous membrane of the stomach 
is not so badly disorganized following the ingestion of caustic al- 
kalies as when some of the corrosive acids are swallowed. The 
contents of the stomach are alkaline in reaction and show dark 
red blood with disintegrated cofinisclos. ^^^lon tlio sohition has 



584 MISCELLANEOUS POISONS 

not been a concentrated one and death does not occur for several 
days, in addition to the inflammation of the mucous membrane 
of the parts over which the caustic has passed, there are often 
found ulcers of the throat, stomach and sometimes the upper 
part of the intestines, together with swelling- and edema of the 
affected parts. In such cases the liver and kidneys are congested 
and the urine is alkaline in reaction and contains albumin. 

CHLORAL 

INFORMATION: Acute poisoning by chloral is most fre- 
quently caused by the taking of overdoses of medicine which con- 
tain chloral or the drug is used by thugs under the name of 
"knockout drops." Chronic poisoning occurs in habitual users 
who take it instead of using opium or cocaine. When chloral is 
administered in the form of knockout drops and death results, it 
is questionable if such a death is covered by an accident policy. 
Weekly or death indemnity is not payable when the drug is vol- 
untarily taken and an overdose produces disability or death. 
Chloral differs in its strength and therefore the quantity that may 
produce a fatal termination is variable. Usually, however, from 
one to two drams will cause death. 

SIGNS AND SYMPTOMS : When an overdose of this drug 
is taken voluntarily or by intent there is usually a short stage of 
excitement which may be accompanied by symptoms of gastric 
irritation. This is followed by drowsiness and deep sleep; dur- 
ing which period the face is livid and covered by a cold sweat, 
the pupils are contracted and on awakening they immediately 
dilate. Respirations are at first slow and deep and later they 
become shallow and feeble, the pulse is slow and then becomes 
rapid, weak and irregular. There is complete muscular relaxa- 
tion with loss of reflexes and death generally follows from respi- 
ratory failure. 

Chronic chloral poisoning exists in individuals who use this 
drug habitually and in such cases the physical and mental condi- 
tion is impaired and many obscure signs and symptoms present 
themselves. There is nervous irritabihty with congestion of the 
eyes and frequently a dermatitis. Chronic indigestion is present 
with poor appetite and the stools are generally devoid of coloring 
matter, due to the inactivity of the liver. Mental impairment 
which shows itself in inability to follow the usual occupation some- 
times ends in insanity. 



CHLORAL 585 

DIFFERENTIAL DIAGNOSIS: Opium Poisoning resem- 
bles that produced by chloral with the exception, however, that 
the pupils are constantly contracted to pin points. Poisoning by 
chloral produces contracted pupils but not to such an extreme 
degree and this contraction does not persist when the individual 
is awakened. 

Coma due to alcohol, drugs and injuries must be differen- 
tiated from coma caused by a toxic dose of chloral and is fully 
considered under Concussion of the Brain. 

HOUSE CONFINEMENT following acute poisoning by 
chloral in which death ensues within twenty-four hours, does not 
last long enough to constitute a claim under a disability policy. 
Chronic poisoning does not produce house confinement, but an 
overdose taken by an habitual user of this drug may cause house 
confinement of from 12 to 24 hours. 

TOTAL DISABILITY following the administration of 
chloral in which death does not follow, usually lasts from i to 2 
or 3 days only, when the individual is sufficiently recovered to re- 
sume the occupation. Chronic poisoning produces short periods 
of I or 2 days of total disability at irregular intervals, and in- 
demnity for such would not be paid by an insurance company 
under an accident or health policy. 

PARTIAL DISABILITY following acute or chronic poi- 
soning by this drug is rarely payable in any case. 

EFFECTS : When recovery follows the accidental swallovr- 
ing of chloral, such a person is insurable for all kinds of insurance 
from two to four weeks after all effects of the drug have disap- 
peared. If chloral is administered in knockout drops, it would 
be necessary to consider the moral hazard before any kind of 
policy could be issued to such an individual. Habitual users of 
chloral are not insurable for any form of insurance and when a 
history of such exists and the drug has not been used- for a num- 
ber of years, an insurance company would wish to consider each 
individual case on its merits; sometimes granting all forms of in- 
surance from three to five or ten years after the drug has ceased 
to be used and at other times refusing to issue any kind of a 
policy, even though the habit had been discontinued. 

POSTMORTEM APPEARANCES are not cliaracteristic 
and this is especially true when death takes place within twelve 
to twenty-four hours. In such cases, however, there niav be a 
bloated appearance of the face and a congestion oi the l^-ain an.l 
spinal cord. If death etisues in habitual users o\ chloral, the body 



586 MISCELLANEOUS POISONS 

is generally emaciated and degeneration of all the prgans is pres- 
ent. 

IODINE 

INFORMATION : Acute poisoning by iodine is usually 
due to the accidental taking of the tincture, although individuals 
who are under treatment for syphiHs and are taking large quan- 
tities of the iodides may develop an acute poisoning, but in such 
cases an insurance company would not pay indemnit}^ under an 
accident policy. The inhalation of vapor from iodine rarely 
causes poisoning. From one-half to one ounce of the tincture 
of iodine will usually produce death and in old tinctures which 
have lost considerable alcohol by evaporation and much concen- 
tration exists, a smaller amount will prove fatal. 

SIGNS AND SY:^IPT0:\IS following acute poisoning by 
the tincture of iodine are referable to the gastro-intestinal tract, 
as this drug acts as an irritant to this part of the body. There is 
headache, dizziness, a sense of constriction in the throat which i 
is accompanied by a burning pain, together with salivation and 
sometimes edema of the glottis. Severe pain in the esophagus, 
stomach and abdomen is complained of, together with nausea, 
violent vomiting and purging. The contents of the stomach 
when vomited are usually a brownish color but if starch is pres- 
ent, the color becomes bluish. The pulse is rapid and feeble, the 
respirations shallow and quickened, while the urine is scanty and 
frequently entirely suppressed. If a specimen is obtained it is 
albuminous and contains casts. When death follows immediately 
it is due to respiratory failure and if this termination does not 
take place for several days, a widespread fatty degeneration of 
the tissues is observed. 

HOUSE CONFINEMENT does not last more than 24 
hours in cases which prove rapidly fatal. Sometimes death will 
not take place until several days after the poison has been swal- 
lowed; in which case house confinement usually lasts from 2 to 5 
days. If a fatal termination does not follow, house confinement 
of I to 2 weeks may be necessary: this time depending on the 
concentration of the tincture, the amount taken, the treatment 
and the rapidity with which it was begun. 

TOTAL DISABILITY in fatal cases of poisoning by the 
tincture of iodine seldom lasts more than 24 hours, although oc- 
casionallv a fatal termination does not take place until from 2 



I 



PTOMAINE POISONING 587 

to 3 or 4 days after the poison has been swallowed. When re- 
covery ensues from i to 2 or 3 weeks may sometimes be required 
before the occupation can be partially resumed. 

PARTIAL DISABILITY exists only in individuals who re- 
cover after taking a toxic dose of iodine. In such cases, on ac- 
count of the inflammation produced and the more or less fatty 
degeneration which results, from 2 to 4 weeks of this form of 
disability may be required. 

EFFECTS :. After recovery from acute poisoning by iodine, 
such a person would be uninsurable for a life, accident or health 
policy until at least one year had elapsed; this time being neces- 
sary on account of the fatty degeneration which may ensue. 

POSTMORTEM APPEARANCES show an acute inflam- 
mation of the mouth, throat and stomach, this also extending 
into the intestines, which are usually empty on account of the 
purging. The mucous membrane of these parts shows a brown- 
ish discoloration, the kidneys are highly congested and the blad- 
der contains Httle, if any, urine and this is albuminous and reveals 
many hyaline and some granular casts. If death does not occur 
until two to three days after the poison has been ingested, fatty 
degeneration of all the organs of the body is found. 

PTOMAINE POISONING 

INFORMATION : Ptomaines are produced by the bacterial 
decomposition of animal matter and ptomaine poisoning is due 
to the eating of various fresh or canned meats, ice cream, milk 
and sea food, which have undergone more or less decomposition. 
This form of poisoning produces gastro-intestinal symptoms and 
is often mistakenly diagnosed for some other condition. The 
period of incubation in the majority of cases is from twelve to 
thirty-six hours, although some cases develop before, while others 
do not begin until after this period has passed. 

SIGNS AND SYMPTOMS are primarily referred to the 
p-astro-intestinal tract. Generallv thev show themselves suddoiilv, 
although sometimes prodromes such as headache, malaise, vague 
pains in the abdomen, etc., precede the attack. Whether it be- 
gins suddenly or gradually it is not liMig until so\ero pain is com- 
plained of in the abdomen and this is stMuetimos accompanied by 
nausea and vomiting. Diarrhea is one of the first early and per- 
sistent symptoms of this condition. Nervousness and weakness 
Avith muscular relaxation are i^-esent in all cases and occasionally 



588 MISCELLANEOUS POISONS 

more or less paralysis of the lower extremities occur. The tem- 
perature usually runs from ioi° to 104° F., the pulse is rapid and 
the urine of high specific gravity and decreased in amount. These 
symptoms gradually disappear as recovery takes place or collapse 
ensues and is followed by death. 

DIFFERENTIAL DIAGNOSIS : Appendicitis, dysentery, 
gastro-intestinal indigestion and other diseases involving the 
stomach and intestines which produce pain and diarrhea must be 
diagnosed from ptomaine poisoning and this can generally be 
accompHshed by the history of the case. 

HOUSE CONFINEMENT following a sHght a^ttack of 
ptomaine poisoning does not often require more than from 3 to 
5 days. Severe poisoning sometimes results in from i to 2 or 3 
weeks of house confinement. The prolongation of this period 
is due in the majority of cases to the persistent muscular weak- 
ness and more or less temporary paralysis of the lower extremi- 
ties. 

TOTAL DISABILITY following ptomaine poisoning is not 
payable under an accident policy, but a general disability policy 
would pay indemnity for this form, of poisoning, provided the in- 
dividual was confined to the house at least seven days. Some fev\r 
companies, however, pay total disability under a health policy 
when the individual is totally disabled less than seven days. Total 
disability of I week usually exists in slight cases of ptomaine poi- 
soning, but severe ones require from 2 to 3 weeks and sometimes 
longer when the disability is prolonged on account of persistent 
muscular weakness or paralysis. 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by the policy after the termination of house confine- 
ment is sometimes allowable and in such cases i to 2 weeks are 
usually sufficient. 

EFFECTS: Ptomaine poisoning leaves no permanent ef- 
fects and therefore from four to six weeks after complete re- 
covery all forms of insurance can be safely issued. 

POSTMORTEM APPEARANCES when death occurs from 
ptomaine poisoning are not characteristic unless an inflammation 
involving the stomach and intestines exists; this being more 
marked in the small and large intestines than in other parts of the 
alimentary canal. 



SNAKE POISONING 589 

SNAKE POISONING 

INFORMATION: When poisoning results from the bite of 
certain reptiles it is considered accidental and is covered by an ac- 
cident policy. Rattlesnakes, moccasins, copperheads and coral 
snakes produce the most poisonous effects of any of the snakes 
found in the United States. The degree of poisoning depends on 
the size and strength of the snake, together with the season of 
the year and the physical condition of the person bitten. It is 
said that snake venom is in the form of a toxalbumose and this is 
ejected from a small slit-like opening on the convex surface of 
the fangs of these reptiles. 

SIGNS AND SYMPTOMS: Immediately after the part is 
bitten there is apparent small needle-like punctures and this is 
soon followed by a burning, stinging sensation and swelling of 
the tissues surrounding the bite or the whole extremity when it 
is on the hands or feet. As the swelling increases the pain be- 
comes intense and is accompanied by nausea and vomiting. 
Great thirst is complained of and evidence of collapse supervenes, 
with a rapid and weak pulse, hurried respirations, muscular re- 
laxation and a cold perspiration which covers the entire body. 
Much nervousness and mental irritability are present. When 
sufficient poison is injected to cause a fatal termination the col- 
lapse is succeeded by coma and sometimes convulsions and death 
which is due to respiratory failure or exhaustion. If recovery 
takes place a reaction sets in and the individual soon passes be- 
yond all danger of a fatal termination from the bite. 

DIFFERENTIAL DIAGNOSIS is seldom difficult, for the 
reason that the individual distinctly remembers being bitten bv 
a snake and almost invariably sees the reptile. In addition the 
marks of the teeth are characteristic, there being at least four 
punctures and when more are present they are not in parallel 
lines but form the sides of a triangle. Insect bites do not cause 
the pronounced constitutional signs aiul symptoms as do snake 
bites and only one point of puncture is iM-escnt. 

HOUSE CONFINEMENT in fatal cases resulting from 
snake bites seldom lasts more than i to J days, the majority of 
such cases terminating within twelve hours. \\'hon death does 
not ensue, house confinement of ivom i to 2 or ^:; days is usually 
ample. 

TOTAL DISABILITY following a fatal case of snake biro 
does not end in a claim for weekly indonmity. but one tor the 



590 GASES 

death indemnity payable by an accident policy vnider such condi- 
tions. When recovery takes place from 3 to 5 or 7 days are 
necessary before the individual is able to resume part of the oc- 
cupation. 

PARTIAL DISABILITY of i to 2 weeks may sometimes 
be demanded when poisoning from a snake bite has been especi- 
ally severe and exerted its main effects on the blood, causing- 
much weakness to result. 

EFFECTS: If a history is elicited of an individual having 
suffered from a snake bite and recovery follows without any un- 
toward symptoms, such a person is insurable for all forms of in- 
surance three to six weeks later, provided the possibility of a re- 
currence of the exposure is eliminated. 

POSTMORTEM APPEARANCES: Rigor mortis appears 
immediately after death and is very characteristic. At the point 
where the bite occurred the tissues have usually been cut out by 
a surgeon; if not, gangrene is present. The bitten part is badly 
swollen and discolored and when this occurs on the extremities 
— as it generally does — the whole extremity shows this condition. 
The blood loses its coagulability and hemorrhages occur into the 
soft tissues and even into the bones, causing a discoloration to 
exist Hemorrhages also occur into the intestines. If any urine 
is found in the bladder it contains disintegrated blood. 



PART IV 

GASES 
CARBON DIOXID 

SYNONYM: Carbonic acid gas. 

INFORMATION: Carbonic acid gas not infrequently 
causes accidental death to those who unconsciously inhale it. This 
gas is odorless and heavier than air, but when mixed with the 
latter and heated, it becomes lighter and ascends. Carbonic acid 
gas is the result of the oxidation of organic matter by the pro- 
cess of decay and by combustion and is produced by oxidation of 
the tissues of the body and consequently exhaled. It is also 
formed during fermentation, the burning of limestone and by the 



CARBON DIOXID 591 

action of acids on carbonates. The gas often accumulates in beer 
vats, old wells, caverns, mines and places which have not been 
used for some time. When it exists in conjunction with the at- 
mosphere in a confined depth, it will prove fatal if the flame of a 
candle is extinguished when placed where this gas exists and 
when this occurs, carbonic acid gas is present in at least eight 
to ten per cent. If the pure gas is inhaled death takes place im- 
mediately, but when diluted with air a fatal termination may not 
ensue for several hours. 

SIGNS AND SYMPTOMS: When this gas is inhaled in a 
pure or concentrated state, death from asphyxiation takes place 
at once. Spasm of the glottis due to the gas may cause death 
by preventing further inspiration and should a sufficient amount 
be inhaled, the individual falls unconscious, with complete mus- 
cular relaxation. If the gas is breathed in a more or less diluted 
form and the person is removed to the open air before death 
takes place, a tingling sensation is complained of in the nose and 
throat, with headache, dizziness, ringing in the ears and a sense 
of oppression, together with drowsiness and loss of muscular 
power. The face is livid or cyanotic, the pupils are dilated and 
rarely nausea and vomiting occur. As the effects of the gas show 
themselves the heart is first stimulated and then gradually be- 
comes weaker, until the pulse is imperceptible. Breathing in 
the early stages of the poisoning is deep and slow and passes from 
this to weak, shallow and rapid respirations. If the inhalation of 
the gas is continued, profound coma ensues and sometimes con- 
vulsions precede the death. 

DIFFERENTIAL DIAGNOSIS by asphyxiation due to 
carbon dioxid is generally made from the history of the case and 
the absence of odor, but the cause of the asphyxiation is never 
important if the individual is seen before death takes place, all 
cases being treated by removal to the open air and artificial res- 
pirations, together with stimulants when needed. The diagnosis 
in such cases is made in ample time if the cause of the asphyxia- 
tion is determined after death or when recovery ensues. 

HOUSE CONFINEMENT is not present in rapidly fatal 
cases of poisoning by carbonic acid gas and no weekly indemnity 
would be payable under an accident or health policy in any case. 
If recovery follows house confinement hardly exists, as the indi- 
vidual by necessity must remain in the open air as much as pos- 
sible. This may sometimes be construed as house confinoniont 
and under such circumstances seldom lasts over j or ^:; days. 



592 GASES 

TOTAL DISABILITY does not exist in fatal cases of poi- 
soning by this gas, but if death was accidental in origin, the fixed 
amount specified in an accident poHcy would become due to the 
heirs of the claimant. When a fatal termination does not follow 
the inhalation of carbonic acid gas, total disabiUty of from 2 to 5 
days is usually ample. 

PARTIAL DISABILITY is not deserved in accidental poi- 
soning by carbon dioxid. 

EFFECTS : When death does not follow the inhalation of 
carbon dioxid and the liability of a recurrence of this form of 
poisoning is eliminated, such a person would be insurable for all 
forms of insurance from three to six weeks after complete re- 
covery. 

POSTMORTEM APPEARANCES : If death results from 
the inhalation of carbonic acid gas the body is usuall}^ swollen and 
livid in appearance, although the face is occasionally pale and in 
repose. The pupils are dilated and postmortem rigidity comes 
on quickly. The right side of the heart, together with the lungs ' 
and large veins of the body are engorged with venous blood 
which does not coagulate readily on exposure to the air. En- 
gorgement of the blood vessels of the bram exists and is some- 
times accompanied by a serous effusion. 

CARBON MONOXID 

SYNONYMS: Illuminating gas; coal gas; water gas; car- 
bonic oxid. 

INFORMATION: Poisoning due to the inhalation of 
water gas, coal or illuminating gas is due to the carbon monoxid 
which they contain and therefore the different names are given 
as synonyms of this gas. Asph3^xiation either by accident or in- 
tent is usually due to the inhalation of illuminating gas and the 
unconsciousness produced by it is caused by the poisonous car- 
bon monoxid with which it is mixed; it usually being present in 
about twenty-two per cent. This gas may also be inhaled in 
toxic amounts, when it is given off during the incomplete com- 
bustion of coal, charcoal or wood. Poisoning due to the inhala- 
tion of gas containing both carbon dioxid and carbon monoxid 
may also exist, but in such cases the carbon monoxid produces 
the more marked symptoms. 

SIGNS AND SYMPTOMS: After the inhalation for a vari- 
able length of time of carbon monoxid, symptoms which resem- 



CARBON MONOXID 593 

ble poisoning by carbon dioxid appear. There is dizziness, ring- 
ing in the ears, extreme muscular relaxation and oftentimes 
tremors and twitching of the muscles. The face is flushed, the 
heart is stimulated, drowsiness occurs and is followed by an irre- 
sistible desire to sleep. The breathing which is at first normal 
in character, gradually becomes slow and deep. When this gas 
has been inhaled f^r some time, dilatation of the peripheral blood 
vessels ensues and results in hemorrhages under the skin. If any 
of these gases are inhaled in poisonous amounts ''the carbon 
monoxid unites with the hemoglobin of the blood, displacing the 
oxygen and producing what may be termed an internal asphyxia- 
tion." (Riley). The complete muscular relaxation which exists 
is said to be due to the action of the gas on the nerve centers. 
Fatal results follow the inhalation of air laden with carbon mon- 
oxid in various quantities and recovery may follow when this gas 
has been inhaled for a considerable time, provided it is suffi- 
ciently diluted with air. When death occurs after the inhalation 
of illuminating gas — which is escaping into a room where outside 
air is not admitted — it usually takes place within one to two hours 
and when illuminating gas is diluted and inhaled sufficiently long 
to produce a fatal result, death may not follow for four to six 
or ten hours. 

DIFFERENTIAL DIAGNOSIS between asphyxiation due 
to carbon monoxid or carbon dioxid is seldom made until after 
death and a postmortem examination is held, when the condition 
of the blood is usually sufficient for this purpose. 

HOUSE CONFINEMENT following rapidly fatal cases of 
poisoning by illuminating gas, does not exist long enough to pro- 
duce a claim under a general disability polic}^ If recovery en- 
sues, modern treatment demands that the individual be kept in 
the open air as much as possible, but this would sometimes be 
construed by an insurance company as house confinement and 
seldom lasts more than i to 2 weeks. 

TOTAL DISABILITY does not exist when carbon monoxid 
is inhaled in a sufficient quantity to produce death and weekly in- 
demnity is not payable under a health or disability policy. If the 
gas is accidentally inhaled and death results, weekly indemnity 
is not payable under an accident policy, but the amount specified 
in the policy becomes due. Should recovery ensue, total disabil- 
ity is generally prolonged and may last from i to 3 or 4 weeks 
and sometimes much longer, on account of soquol:v that may fol- 
low the inhalation of this gas. Insurance coni]xinios. thorotoro. 
38 



594 GASES 

endeavor to secure a release when any liability exists after the 
accidental inhalation of carbon monoxid at an early date, be- 
cause of the possible impairment of the mental activities. 

PARTIAL DISABILITY following the accidental inhala- 
tion of this gas may sometimes be required in non-fatal cases in 
the settlement of a claim under an accident policy, and in such 
cases from i to 2 or 4 weeks m.ay be demanded and become pay- 
able. 

EFFECTS : When an individual has accidentally inhaled 
illuminating gas and recovery follows, insurance of all kinds can- 
not be safely issued to such a person until at least one to two 
years after the date of inhalation and not even then until after a 
medical examination shows the ph3^sical condition to be normal 
and the possibility of a recurrence of the accident is ehminated. 

POSTMORTEM APPEARANCES: The body is generally 
swollen and postmortem rigidity appears early. The pupils are ' 
dilated and the face flushed in appearance and rose-colored spots 
due to hemorrhages under the skin are seen covering the entire I 
body. When the body is first opened the odor of gas is apparent 
but this disappears in time. After poisoning by carbon monoxid 
the condition of the blood is characteristic and sufficient for diag- 
nosing death by illuminating gas. When this gas is the cause 
of the fatal termination, the blood is bright red in color and has 
lost its power of coagulating. The organs of the body — especi- 
ally the brain — are softened and rapidly undergo decomposition. 

HYDROGEN SULPHID 

SYNONYM : Sulphuretted hydrogen. 

INFORMATION : Hydrogen sulphid is a colorless gas with 
a strong penetrating odor, resembling that given off from rotten 
eggs, and consequently accidental poisoning from its inhalation 
never occurs except in the concentrated form. This gas results 
from putrefaction of animal matter and is usually combined with 
others, being one of the principal constituents of sewer gas. 

SIGNS AND SYMPTOMS: When hydrogen sulphid is in- 
haled in the concentrated form death quickly results and is due 
to the narcotic action of the gas and its effect on the nervous sys- 
tem. If breathed for a few minutes the individual falls uncon- 
scious and respirations quickly cease, although the heart con- 
tinues to beat a short time after breathing stops. Sometimes re- 
covery follows if the person is promptly removed to the open air. 



HYDROGEN SULPHID 595 

Laborers working in trenches and sewers in which this gas is 
present in a very diluted form, complain of headache, cough, 
difficulty in breathing and burning sensation of the eyes, nose and 
throat. When the gas is not so diluted the above signs and 
symptoms are soon followed by nausea, sometimes vomiting, 
muscular weakness, unconsciousness and death. If the gas is 
inhaled in a more or less diluted form, its effects may not be- 
come apparent until after the individual has left the place Avhere 
the gas is present and sometimes not until after fifteen to thirty 
minutes have elapsed. Inhalation of the concentrated gas pro- 
duces death within a few minutes, the individual rarely living 
longer than ten minutes after the inhalation has begun. In a 
more or less concentrated form death may not take place until 
one to two or three days later. 

DIFFERENTIAL DIAGNOSIS is usually made without 
difficulty on account of the odor which is present and which is 
noticed by any one in close proximity to the source of the gas. 
The breath often reveals the odor of this gas for some time after 
it has been inhaled. 

HOUSE CONFINEMENT after the inhalation of concen- 
trated hydrogen sulphid does not exist as death occurs at once. 
When the gas is inhaled in a diluted form, house confinement 
may last from i to 3 days and be terminated by death. If this 
does not take place and recovery folloAvs, house confinement de- 
pends on the degree of concentration of the gas and the length 
of time it has been inhaled. Usually in poisoning by hydrogen 
sulphid absolute house confinement does not exist, as modern 
medicine demands the open air treatment, although in such cases 
an insurance company would generally be liberal in construing 
the term house confinement and allow from i to 2 weeks for this 
form of disability. 

TOTAL DISABILITY is not payable under a health or 
disability policy when death ensues, but if this termination is ac- 
cidental in origin the amount specified in an accident policy would 
become due. Oftentimes death does not occur immediately bur 
takes place within 3 days after the inhalation of the gas. Should 
recovery follow the inhalation of hydrogen sulphid total disability 
varies, lasting from i to 2 or 3 weeks; this lime depending cmi the 
length of time the gas was inhaled, its tlcgroo o\ concentration 
and physical condition of the individual. 

PARTIAL DISABILITY wotild seldom bo payable under 
an accident policy following the inhalation of this gas. 



596 GASES 

PARTIAL INDEMNITY FOR TOTAL DISABILITY 
if payable by a health or general disability policy after the ter- 
mination of house confinement, sometimes requires from i to 2 
or 3 weeks. 

EFFECTS : After poisoning by hydrogen sulphid, such a 
person would be considered uninsurable for a life or health policy 
until at least three to six months had elapsed; this being due to 
the action of the gas on the red blood corpuscles rendering them 
incapable of carrying oxygen to the tissues. Accident insurance 
in such cases, however, could usualty be issued with safety from 
three to six weeks after the occupation was resumed. 

POSTMORTEM APPEARANCES are not characteristic, 
the body presenting externally no evidence of the cause of the 
death. A brownish viscid mucus is often found covering the mu- 
cous membrane of the nose and throat, the lungs are engorged 
and filled with dark fluid blood, which has lost its power of coagu- 
lating. The right side of the heart is also engorged and filled 
with blood of the same character. ' Oftentimes when death does 
not follow immediately, minute hemorrhages occur in all parts 
of the body, causing a brownish discoloration of the tissues. Post- 
mortem rigidity is slow in appearing and putrefactive changes 
take place rapidly. 



CHAPTER XXII 

ADJUSTING CLAIMS FOR DISABILITY RESULTING FROM 
ACCIDENTS OR DISEASES 

PART I 

ACCIDENT CLAIMS 

A successful accident insurance company is one in whom its 
policy holders have confidence and who are pleased and satisfied 
with the treatment accorded them in the settHng of their claims. 
These claims arise whenever a poHcy holder suffers from an acci- 
dent, even though it may be so trivial that no liability exists on 
the part of the company to pay any indemnity, the claimant not 
being either totally or partially disabled for a sufficient time to 
entitle him to indemnity, but the claim must receive attention 
and it must be some one's duty to pacify those who make claims 
under a misunderstanding. For this purpose, accident insurance 
companies have employees who are known as adjusters and whose 
business it is to adjust and settle any claim arising under an ac- 
cident policy. An adjuster is usually a man of good address, 
pleasing manners, one who can make himself agreeable with any 
claimant and who knows thoroughly the conditions of the policy 
under which he is attempting to make a settlement. In addition 
to adjusters, insurance companies permit their general agents and 
in some cases the examiners to make settlements of claims aris- 
ing under accident policies. A physician who examines for an 
insurance company and knows the policy forms in addition to 
being able to handle different individuals in the proper way, 
makes an ideal adjuster, for the reason that his medical knowl- 
edge teaches him the probable duration of the disability as suf- 
fered by the person with whom he expects to make an adjust- 
ment. In addition to his medical qualifications, he is in a better 
position to make a settlement of the claim immediately after he 
has made the examination, as claimants who are suffering from 
a more or less trivial injury that will cause total or jxirtial dis- 

597 



598 ADJUSTING ACCIDENT CLAIMS 

bility of one to three weeks are usually in a better frame of mind 
for a settlement at this time than if the doctor has to make the 
examination and send in his report to the office, and his visit in 
turn is followed by the adjuster who may arrive from one to seven 
days after the doctor's visit and during which time the claimant's 
condition has not improved as much as anticipated. A doctor 
in making an adjustment must be prepared to use ah the qualifi- 
cations possessed by an adjuster without a medical education, 
and these include knowledge of policy forms, tact and ability to 
protect the interest of the company and satisfy the claimant; as 
by a successful adjustment, the company not only gains in dollars 
and cents, but also gains new policy holders by paying the proper 
amount for a claim, thus advertising the business and also the 
fact that that particular company pays its claims fairly and 
promptl}'. A physician who makes a successful adjuster for insur- 
ance companies is one who is always ready to listen and learn 
anything about adjusting, but who never talks about the business 
of one company to the agent or representative of another com- 
panv. 

'definition of an ACCIDENT: All accident insur- 
ance policies define an accident as ''an injury which may be seri- 
ous or trivial in character, but which occurs to an individual 
through external, violent and accidental means.'' A number of defi- 
nitions for the word '"accident" have been formed by different 
individuals, the following of which is considered a very good 
one : ''An event which takes place without the over-sight or ex- 
pectation of the person acted upon or affected by the event." 
The Centur}^ Dictionary states that an accident is in general, "any- 
thing that happens or begins to be without design, or as an un- 
foreseen effect, an undesirable or unfortunate happening; an un- 
designed harm or injury; a casualt}^ a mishap or a happening 
without intentional causation." An individual who carries an ac- 
cident insurance policy and expects to make a claim for indem- 
nity must therefore suffer from an injury defined as above and 
which has been sustained by him through external, violent and 
accidental means. As for example, in walking along the street 
a slip of the foot occurs which is followed by a fall and a sprain 
of the ankle. This is an accident pure and simple, the individual 
slips accidentally, falls violently and sustains an injury which is 
visible externally. If the same individual is walking calmly along 
the street and feels something give away in his leg and this is 
followed bv disabilitv, he is not entitled to indemnitv under an 



KNOWLEDGE OP POLICY FORMS 599 

accident policy, because the injury which may be a tear of the 
muscles of the leg is not sustained by violent or accidental means. 
Some persons claim indemnity for accidents when the disability 
is due to over-exertion, such as a sprained back due to lifting in 
which there is no history of an accident, the injury being the re- 
sult of a test of strength. Physicians often claim indemnity under 
an accident poHcy when disabiHty is caused by blood poisoning 
and the infection is due to absorption through an open wound 
which is not produced at the time the infection occurs. Such 
cases are not covered by an accident policy as the infection has 
not been sustained in a violent, external or accidental manner, 
but follows the entrance of poison to the circulation by means of 
an open wound which has been existing prior to the time that 
-the infection began. 

KNOWLEDGE OF POLICY FORMS: If an examiner 
expects to adjust accident claims for an insurance company, he 
must make himself familiar with the poHcy forms as issued by 
the company for which he is adjusting. If he does not know the 
conditions of the different policies, it is an impossibility for him to 
make a satisfactory adjustment either to the company or the 
claimant. It is not sufficient to know that an injury to be covered 
by an accident policy must be produced by violent, external or 
accidental means, but the important parts of the policy must be 
known, especially that part which defines total and partial dis- 
abiHty and a number of other conditions which are essential for 
a successful adjuster to know and which are described under 
Chapter IV. A number of insurance companies at the present 
time are dupHcating the policies of all other competitors. This 
makes it impossible for any one to carry in mind all the conditions 
of the different accident insurance policies, but if a physician will 
learn the important ones, he can usually depend on that knowl- 
edge for the purpose of making a settlement when the policy as 
held by the party is not at hand for reference. 

EARLY ADJUSTMENT: It is recognized by every insur- 
ance company and corporation that an early adjustment of a per- 
sonal accident claim against them is to their best interest auvl 
the quicker a settlement can be effected and the claim paid and 
the papers put awa}^ the less will it cost the company for that 
particular case. This is especially true in accident insurance 
where advance settlements are often possible. When an indi- 
vidual suffers from an accident that will cause total or partial dis- 
abilitv to last from one to three or fom- weeks and there will be 



600 ADJUSTING ACCIDENT CLAIMS 

no permanent impairment of the function of the parts injured, 
it is almost ahvays possible to secure an advance settlement and 
especially if the adjuster knows how to handle the party who has 
been injured. Advance settlements in accident cases benefit 
the company greatly in many ways, chiefly by advertising and re- 
ducing the amount paid out on claims. It soon gains a reputa- 
tion of paying its claims promptly and this alone is sufficient to 
increase its business and especially when these claims are paid in 
advance, the company gets more credit for an early and equitable 
settlement of its obligations. The company not only gains by in- 
creasing its reputation and enlarging its business, but also gains 
financially, as the claimant, if not paid in advance has no incentive 
to return to work earHer than is absolutely necessary and does 
not do so, but waits until he — and perhaps an obliging doctor — is 
sure he is fully recovered. If a claim is paid in advance, the in- 
jured party will go back to work before the termination of the 
time for which he has been paid if he can possibly do so and this 
will be done without any injury to himself or the company which, 
although it may settle a number of claims in advance and pay for 
a day or two more than the individual required and thus appar- 
ently lose that time, yet will gain in the end, as claims settled after 
the termination of disability are always for a longer period of time 
than if settled in advance. The claimant is benefited by an early 
adjustment in having the use of the money which is paid him dur- 
ing the period of his disability and at a time when his income has 
ceased or is continued through the charitable feelings of his em- 
ployers. If the disability ends before the time for which the in- 
demnity has been paid, the claimant is perfectly satisfied with 
himself and the company as he beheves he has made a sharp set- 
tlement with them and has been paid for time that he was not 
disabled. If his disability persists longer than anticipated, he 
usually considers that he has had the use of his money during 
the time that he was laid up and is rarely dissatisfied because he 
was not paid for the full time disability lasted. An early adjust- 
ment therefore is most desirable for an insurance company, allow- 
ing them to get rid of the case and permitting attention to be 
given to other matters, and at the same time reducing the cost 
of the claim and advertising the company as one which pays its 
claims promptly and in advance. 

MANNER OF ADJUSTMENT: Experiences teaches a 
physician or adjuster the manner in which to attempt an advance 
settlement of the various cases that are selected for this purpose. 



MANNER OF ADJUSTMENT 601 

It is not always to the best interest of the company that an early 
adjustment be made; for example, if an individual is suffering 
from a fracture of the femur, a physician or. adjuster will hardly 
attempt to make an advance settlement as it would be almost im- 
possible to anticipate the correct time 'that such an individual 
would be disabled and prevented from doing all or part of his oc- 
cupation. Sometimes, however, even in these cases there are con- 
ditions such as poverty, the probable loss of the leg or a death 
within ninety days that would cause an adjuster to attempt to 
force a settlement. In the first case, it would be to the advantage 
of the claimant while in the latter two, the company would be 
saved such a great amount of money in excess of the amount that 
would have been paid out for the loss of the leg or loss by death, 
that it can afford to take chances on any criticism that may arise. 
Individuals who are disabled by accidents which are so severe 
that the disability will last for months and perhaps terminate in 
death should always be settled in advance if possible, by the ad- 
juster securing a release for the company at the smallest possible 
figure, even though at the cost of considerable criticism, as criti- 
cism does not pay the expenses of running an insurance com- 
pany and money which can be saved is that much earned. 

There are a number of ways of coming to an adjustment with 
the claimant and different adjusters have different methods of 
doing this. A good adjuster will use all methods, adapting each 
one to the individual case under consideration. Some adjusters 
ascertain the probable length of duration of disability before see- 
ing the case and then learn from the party the time demanded. 
With these two extremes in view, an amount is agreed upon and 
paid. Another way is for the adjuster to offer a certain figure to 
the claimant and induce the party to accept that amount or a 
sHght increase. Adjusters usually base their settlements on days 
and weeks of total or partial disabilit}^ and then compute the 
amount in dollars and cents according to the time allowed. Some- 
times, however, an adjuster will offer a lump sum for the settle- 
ment of a case, but before doing so he has secured the probable 
length of disability and counted in his own mind the amount of 
indemnity payable, although this is not always necessary as he 
may know from experience that his company is willing to pay a 
certain lump sum for a specified injury which occurs to an indi- 
vidual who is carrying a policy for a certain amount. If a physi- 
cian himself is adjusting the case, in order that the olaininni may 
[not think that any advantage is taken of him. it is always well to 



602 ADJUSTING ACCIDENT CLAIMS 

ask for the prognosis of the attendmg physician, as this tends 
to show that the examiner has no intention of using his medical 
knowledge to gain an unfair advantage over the claimant. If the 
prognosis of the attending physician is below that of the examiner 
and he thinks such a time would be a fair settlement, the amount 
can be paid at once and the case closed. Should the attending 
physician's prognosis be too long, — and this is usually the case — 
the examiner can explain to the claimant his reasons for thinking 
differently and in many cases convince the injured party that the 
prognosis as given by the attending physician is excessive and 
thus secure an advance settlement. In making an adjustment of 
an accident claim, it is necessary that the adjuster know the 
claimant's weekly income from his occupation and also know the 
amount of insurance carried by the individual, for the reason that 
accident insurance poHcies contain a clause whereby the company 
is liable only for its proportionate share of the weekly loss of 
wages suffered by the claimant; in other words, if an individual 
is making Twenty-five Dollars per week and carries two policies 
each paying Twenty-five Dollars per week or Fifty Dollars in all, 
and he is laid up one week, each company would pay Twelve Dol- 
lars and Fifty Cents thus making Twenty-five Dollars the amount 
that the claimant would have earned had he been at his usual oc- 
cupation. This provision is necessary for the purpose of prevent- 
ing the prolongation of claims and must not be overlooked in any 
case when a settlement is effected. 

MANNER OF PAYMENT: Settlements are usually made 
by paying cash, check or draft. Accident companies doing what 
is known as an industrial accident business or that class of busi- 
ness where they insure their policy holders by the week or month, 
usually pay their claims in cash, as this class of people are not fa- 
miliar with checks or drafts and a cash payment is much more 
desirable and convenient to them than any other. Companies in- 
suring the better class such as merchants, lawyers, physicians, 
etc., generally pay their claims by checks or drafts; this depend- 
ing on the custom of each individual company. In whatever man- 
ner these claims are paid, however, each compan}^ takes what is 
known as a release and this releases the company from all liability 
of' any claim for damages arising under the accident for which in- 
demnity has been paid. These releases are printed on separate 
paper for cash payments a.nd the same method is also used by 
some companies when payment is made by check or draft, while 
others have the release printed on the back of the check or draft 



PROVISIONAL SETTLEMENT 603 

and by the indorsement of the paper, the mdividual releases the 
company for that particular claim. 

PROVISIONAL SETTLEMENT: An examiner of an in- 
surance company who is not authorized to settle cases can fre- 
quently assist his company very materially by securing a provi- 
sional settlement and b}^ this is meant, ascertaining from the 
claimant the amount of time that would be satisfactory for total 
and partial disability, if one or both exists. When such a settle- 
ment is secured by the examiner, great care must be taken in 
telling the claimant that the amount of time that has been fixed 
between himself and the examiner will be stated to the company, 
but not recommended to them as being considered satisfactory 
by the examiner. If the examiner in agreeing upon the time for 
the settlement of the disabihty, should say to the claimant that he 
would recommend that time to the company, he places the insur- 
ance company in a position that they must either pay that amount 
or cause dissatisfaction. The home office ofhcials may consider 
the time as agreed upon by the doctor and the claimant as en- 
tirely too long and refuse to pay it. If the claimant is notified 
that such action has been taken, he immediatel}^ becomes dissatis- 
fied and states that the examining physician of the insurance com- 
pany recommended that he receive a certain amount, and the 
company is often compelled to pay the claim at a figure which 
they consider too high or cut it down with resulting dissatisfaction. 
If the examiner has been careful to tell the claimant that he would 
simply inform the company that the amount agreed upon would 
be acceptable to the claimant and not say that he would recom- 
mend it, the company could take whatever action it considered 
necessary and the claimant is not in a position to say that the 
examining surgeon of the insurance company recommended such 
an amount for his claim and the company would not pay it. These 
provisional settlements if properly made, assist an insurance com- 
pany very much and at the same time the examiner receives credit 
for looking after the interests of the company, thus increasing his 
standing with them; while if such settlements are made in an un- 
skilful and unsatisfactory manner, he is censured and probably 
requested to abstain from attempting an adjustment in future cases 
that he may be askfed to examine. 

ABILITY TO DETECT FRAUDULEXT CLAB[S: Ac- 
cident insurance" policies are sold by agents who are j'jaid a com- 
Imission on every policy they sell, and it is thoroforo to tlieir in- 
terest to sell as nuich insurance as the\" can. A groat nian\- agents 



604 ADJUSTING ACCIDENT CLAIMS 



% 



are conscientious and will not sell an insurance contract to an in- 
dividual whom the}^ do not consider trustworthy or one whom 
they know is not a desirable risk, but a number of them are not 
so constituted and will place a policy with any person whom they 
can get to pay for it. For this reason there are individuals carry- 
ing accident insurance who are not of the highest integrity and 
who are generally on the alert to defraud an insurance company 
at the shghtest opportunity. This condition of affairs does not 
exist altogether among the class of people who would take ad- 
vantage of every trivial injury, but can be found among the very 
best class in the community. There seems to be a sentiment pre- 
vailing among a number of people that it is no crime or theft to 
beat an insurance company out of a large or small amount of 
money and a number of individuals will not hesitate to claim in- 
demnity and push the payment of their claim for slight accidents 
or prolong the period of disability unnecessarily, when they in 
their own minds know that they are not rightfully entitled to the 
amount demanded. This is a condition which should not exist 
but which unfortunately does exist among a large number of 
claimants. For these reasons, a physician who is examining for 
an insurance company can never tell when he ma}^ be called upon 
to detect a fraudulent claim. The fact that he is examining some 
one who holds a respectable position in the community does not 
permit him to be neghgent in any part of his examination, as he 
may find a fraudulent claim among any class of people. These 
claims, however, which are fraudulent in intent from the begin- 
ning are usually found among the lower classes w^ho would not 
hesitate to secure indemnity or get back some of the money they 
have paid the insurance company at every opportunity which pre- 
sents itself. A successful insurance examiner is one who is con- 
stantly on guard for fraudulent claims and who has the ability 
to detect them, and when found does not hesitate to transmit his 
opinion to the home office of the company. Opinion alone, hov/- 
ever, that a case is fraudulent is not suf^cient and the examiner 
must endeavor, if possible, to produce proof that his opinion is 
correct and that the claimant is demanding indemnity for some- 
thing that is not covered by his policy. 



HEALTH CLAIMS 605 

PART II 

HEALTH CLAIMS 

The method of adjusting claims for disabihty when the in- 
dividual is covered by a health poHcy, is entirely different from 
that of adjusting accident claims, and while a local adjuster may 
be able to make a satisfactory settlement of practically all claims 
arising under an accident policy, he is usually incompetent to 
settle health claims and for this reason very few companies permit 
these claims to be settled outside of the home office. An adjuster 
or some home official who settles health claims, must know more 
or less about all diseases, that is to say, he must have a working 
knowledge of the synonyms of diseases, the prominent signs and 
symptoms, the usual complications, with the length of time dis- 
ability is prolonged by them, the diseases which are venereal in 
origin, etc. When a claim for disability caused by sickness is re- 
ceived by an insurance company, it usually asks for an examina- 
tion of the claimant by its examining physician, and if the infor- 
mation thus secured indicates that the disability is going to last 
from two to four weeks, no further attention is given it until 
about the time it should terminate, when the completed claim 
papers are received or the claim examiner seeks further informa- 
tion concerning the prolongation of disability. When these 
papers are received at the home office, they contain in addition to 
the statement of the claimant, a statement of the attending phy- 
sician which gives the length of time house confinement lasted, 
together with the duration of total disability, and some com- 
panies demand the length of time the individual is convalescing 
and not confined to the house, but unable to attend to any part 
of the duties of his occupation. Under these circumstances, if 
the claim is an average one for the disease, it is usually settled by 
the claim examiner sending to the claimant a check or draft from 
the home office of the company. Thus it will be seen that these 
claims of average duration are generally \rd\d on the certificate 
of the attending physician. Companies usually require a certifi- 
cate from the agent stating these facts, but as the agent in most 
cases simply makes out these statements after having received 
information from the attending physician as to the contents of 
his report, they are of little use except ]H^rhaps to ser\ e as a 



606 ADJUSTING HEALTH CLAIMS 

check on the agent. Some companies permit a few of their ex- 
aminers to settle health claims, but these physicians are of course! j 
adjusters and are thoroughly familiar with the terms of both acci- 
dent and health insurance policies, and are therefore just as com- 
petent to settle health claims, as the claim examiner at the home 
office. When a company permits settlements of this kind, it is 
sometimes possible for the examiner and adjuster of the com- 
pany to settle a case at or before its termination by giving a sight 
draft on the company for the probable amount due. 

DEFINITION OF DISEASE: Health or sickness policies 
as issued by insurance companies, promise to pay the holder a 
specified sum for disability incurred under certain conditions The 
main one of which is, that the individual must be disabled from 
engaging in any work or occupation for wages or profit by reason 
of a disease Some policies specify a certain number of diseases 
for which indemnity is payable and unless the disability is caused 
by one of the diseases enumerated in the policy, the individual is 
not entitled to indemnit}'. When an individual carries a general 
health policy, he is entitled to indemnity for disability which is' 
produced by any disease, provided the other conditions of the 
policy are observed. A disease is considered to be a ''deviation 
from the health or normal condition of any of the functions or 
tissues of the body. It is a morbid, painful or distressing physical ; 
condition which may be acute or chronic and which may result in | 
death or in a more or less complete return to health." Even 
though an individual may not suffer from a well developed dis-, 
ease, but only have the signs and symptoms of a certain illness; 
in a mild form and these cause disability, he is entitled to indem- 
nity under a general health policy, provided there is nothing in' 
the policy to the contrary. 

KNOWLEDGE OF POLICY FORMS: When an insur- 
ance company permits its examiner to adjust and settle claims 
arising under a health or disability policy, it does so after the ex- 
aminer has proved himself a good adjuster of accident claims and 
has shown that he has become acquainted with the conditions of 
health policies. Limited health policies pay indemnity for cer- 
tain diseases which are named therein. General health policies 
pay for disability caused by a disease, — subject to certain condi- 
tions of the policy, — among which are, that the claimant must be 
totally disabled for at least one week: and total disability shall 
not be payable unless house confinement existed; some pay par- 
tial indemnity for total disability following a period of house con- 



ADJUSTMENT 607 

finement or for the time that the claimant is convalescing from 
a disease. A number of companies now issue health policies which 
pay indemnity for disability under one week and some policies do 
not require house confinement. 

A, health policy does not become effective until a certain 
length of time has elapsed after its date — from fifteen to ninety 
days — therefore, this is also one of the important conditions that 
must be known and remembered. A physician who can adjust 
an accident claim and who has become familiar with the condi- 
tions of the different kinds of health policies should make a good 
adjuster of health claims; but it can be readily understood by the 
few examples enumerated above, that this branch of adjusting is 
much more difficult and requires a better knowledge of the con- 
struction of health policies than if the claim existed under an 
accident contract. 

ADJUSTMENT: If an individual is suffering from a dis- 
ease, it is almost impossible to tell the exact time when he will 
have recovered; therefore, early settlements in health cases can 
only be effected when the disease is one which will cause disabil- 
ity to probably last from one to two or three weeks; such cases 
as grippe, bronchitis, lumbago and a few of the diseases of child- 
hood which occur in adults, come under this category. An early 
settlement of a health claim is not always advisable from the view- 
point of the company, on account of the uncertainty of the dura- 
tion of the disability. If an individual settle^ his claim in the early 
part of his illness and is disabled from one to three weeks longer 
than is anticipated, it is almost certain that the company will be 
requested to pay the additional amount and if not paid, dissatis- 
faction results. It is the practice of a number of adjusters who 
have the authority to settle health claims, to never settle in ad- 
vance a claim for disability under a health policy which is going 
to last from one to three months or more. In such cases, the ad- 
juster will wait until the termination of the disease has about ar- 
rived, when he will be better able to estimate the probable length 
of the remaining disability and thereby cff'ect a settlement that is 
satisfactory to the company. In some cases where disability ex- 
ists and is covered by a health policy, and it is apparent that this 
disability will continue to last and exceed the limit oi the ]HMicy, 
it is sometimes possible to settle the case some weeks in advance 
of the termination of liability on the part of the company by the 
payment of indemnity for iM-actically the limit of the ncMicv. oven 
thouo-h one to two or three weeks only are cut otT from the 



608 ADJUSTING HEALTH CLAIMS 

amount that would eventually have to be paid the claimant, it is 
that much of a saving to the company, and as the individual re- 
ceives the money from one to two or there months in advance, 
he is usually willing to accept this loss of a week or more and 
have his indemnity when it will do the most good. 

THE MANNER OF ADJUSTING HEALTH CLAIMS 
depends on the disease which is causing the disability. If it is 
thought that the disabilit}^ will be short, lasting only from one 
to two or three weeks and the opinion of the attending physician 
has been ascertained and found to concur with that of the exam- 
iner, then it is possible in some cases to secure a settlement, by 
agreeing upon a time with the individual who is disabled, paying 
the claim and taking a release at once AVhen the disease is one 
that will cause disability to last from three to six or eight weeks 
or more, it is rarely possible to secure an adjustment until near 
the termination of the disability, when the examiner should con- 
sult with the claimant and the attending physician, and agree 
upon a time for which total disability is to be paid and also par- 
tial indemnit}^ for total disability, if the policy provides for that 
contingency. In such cases, the company usually requires that 
the claimant and attending physician fill in a claim blank which is 
furnished them, and then, after this claim blank has been sent to 
the home ofhce and passed upon by the claim examiner or medi- 
cal director, the amount is allowed and a check or draft delivered 
to the claimant, at the same time securing the release. Claimants 
under a health policy will seldom make a settlement with an in- 
surance company for disabiHty due to sickness, until after they 
have consulted the attending physician and learned his views as 
to the length of time that disability will probably continue. It 
can therefore be seen that the manner of adjusting a health claim 
is entirely different from one arising under an accident policy 
and it practically means in all long cases of disability, that the 
termination must be awaited before a settlement can be efifected. 

MANNER OF PAYMENT: Health claims are paid by 
cash, check or draft and in each case when paid, a release is se- 
cured from the claimant. Some companies doing what is known 
as an industrial accident and health business, pay some of their 
claims weekly, that is, in a case which will probably last from 
two to four or six weeks, the company advances the amount due 
each week, thus enabling the poHcy holder who is usually in poor 
circumstances, to pay part of his expenses as they are incurred. 
It is questionable if this method of making partial payments on 



FRAUDULENT CLAIMS 609 

health claims is advisable or not. It may and probably does help 
to advertise the company and thus secure some increase in busi- 
ness, but it certainly does not reduce the amount of claims, as an 
individual who is ill and belongs to the laboring class is not going 
to return to work any earHer than is absolutely necessary, especi- 
ally if he is receiving from an insurance company the amount due 
him weekly. He has no incentive to return to work, for the 
reason that he probably receives almost as much while being sick 
as he would receive if he was attending to his usual occupation, 
and he considers that he is having a vacation and is perfectly will- 
ing to remain away from work as long as possible, even though 
his income may be somewhat restricted. 

FRAUDULENT CLAIMS under health poHcies are not as 
frequent as under an accident policy. There are, however, a num- 
ber of cases of illness which are trivial or of short duration and 
which are prolonged beyond the time they should be, and thus 
the claim for indemnity, while not fraudulent in the beginning 
is fraudulent, inasmuch as it is prolonged beyond the time the 
disability actually lasts. Some diseases admit of fraudulent claims 
much more readily than do others, such as neurasthenia, lumbago 
and similar illnesses in which there is no external evidence of the 
disease, but only symptoms which are claimed by the individual 
and which may not exist. All claims for neurasthenia, muscular 
rheumatism, dysentery, etc., should be most closely investigated, 
as an examiner may find a fraudulent case under the most unex- 
pected conditions. To be able to detect these fraudulent claims, 
it is necessary that the examiner be thoroughly familiar with all 
the signs and symptoms of different diseases and also know how 
to apply different tests for the purpose of verifying the statement 
of the claimant, thus proving that the individual is suffering frotn 
the disease and is not simply making a claim for disability which 
does not exist. 

DIFFERENTIAL DIAGNOSIS: A successful insurance 
examiner who examines many health cases for an insurance com- 
pany, is one who is thoroughly competent to make a differential 
diagnosis on the first visit and to do this, he must be well read on 
the signs and symptoms of all diseases, if not, it is impossible to 
make a correct diagnosis or to detect fraudulent claims when they 
arise. Insurance examiners are usually paid by the company for 
one visit only, and at that time they are expected to make a dif- 
ferential diagnosis and this is extremely difficult in a number of 
cases, especially when the claimant is ignorant or is a foreigner 
39 



610 ADJUSTING LIABILITY CLAIMS 

and is unable to make himself miderstood or when there is an 
attempt at fraud and the claimant will not answer questions or 
will answer them in an untruthful manner. The examiner must 
frequently depend altogether on his power of observation and 
ability to diagnose the disease from the physical signs alone, and 
in some cases this is very difftcult. A good examiner in such 
cases will use every method known to science that will assist him 
in making a proper diagnosis, and he must be prepared and be 
famihar with all the latest methods and instruments which may 
be required for this purpose. 



PART III 

LIABILITY CLAIMS 

A liability claim is one arising from an injury sustained by 
some one who is not insured by the insurance company which is 
Hable for the acts or negHgence of the employees of another cor- 
poration, and therefore in adjusting such a claim there is no 
contract existing between the injured party and the insurance 
company or the corporation which may be liable for the injury 
sustained by the claimant. This condition of affairs places the 
claimant in an entirely different light toward the insurance com- 
pany than if a contract existed between them for the purpose of 
settling a claim under such conditions, it is therefore necessary 
that some one who is skilled in the law of liability, either an at- 
torney or one who has made a study of this branch of the law, be 
employed for this purpose and this makes it imperative that in- 
surance companies have a separate department for the settle- 
ment of this class of claims. Physicians who are good examiners 
and good adjusters of accident and health claims, when these 
claims arise under accident and health pohcies are not competent 
except in rare instances to make an adjustment for a liability case, 
unless some one who is competent to pass on the question of lia- 
biHty of the company first decides that the company is Hable; in 
which case an examiner may sometimes be able to secure an ad- 
justment after having been given the limit that the company 
would pay for a release. There are very few physicians who are 
permitted to settle liability cases and these fcAV are usually men 
who have made a special study of the law of liability and who are 



LIABILITY CLAIMS 611 

engaged in that branch of the work all the time, not even adjust- 
ing accident or health claims under personal accident or health 
policies; and it is not deemed advisable by those in authority with 
insurance companies that a physician attempt this branch of the 
business. If an individual has been injured through the negli- 
gence of another party and that party is covered by a liability 
policy which is issued by an insurance company, almost the first 
move of the injured party in the majority of cases is to consult 
an attorney and place the case in his hands. When such action 
is taken it can readily be seen that a physician is not competent 
to handle the case. An attorney for the company or one who is 
famihar with the law and has had much experience in adjusting 
in this line, must be selected; if not, an insurance company would 
soon be paying out so much money on trivial claims and ones in 
which the liability was doubtful, that the premiums would be re- 
quired to be increased to such an extent that the company would 
be forced to stop writing that branch of the business, being un- 
able to compete with other cornpanies whose claims were passed 
upon by a competent liability adjuster. 



CHAPTER XXIII 

METHODS OF SECURING APPOINTMENTS AS EXAMI- 
NER FOR INSURANCE COMPANIES, AND WHEN 
APPOINTED, HOW TO COMMAND EXAMI- 
NATIONS IN COMPETITION WITH 
OTHER PHYSICIANS 

The desire on the part of physicians to be appointed medical 
examiners for insurance companies and fraternal organizations 
is a condition which constantly exists. It would probably be sur- 
prising to a physician who is not connected with the home office 
of an insurance company to know how many physicians ask how 
they can secure an appointment as examiner. This desire on the 
part of doctors is a natural one however, as they realize in a more 
or less vague manner the benefits which accrue to a physician 
who has been appointed as examiner for one or more insurance 
companies or fraternal organizations. It is a recognized fact 
that there is a way for accomplishing everything, and in order 
that a physician may secure an appointment for any organization 
or corporation that requires his services, it is necessary that he 
proceed in the proper manner. Very few physicians know how 
to obtain these appointments with insurance companies in the ac- 
cident, health or liability business or with fraternal organizations, 
and it is therefore the intention if possible, to point out how they 
can be secured in the quickest and easiest manner. 

BECOMING WELL KNOWN: Successful physicians are 
men whose names and deeds are known to a great number of 
people and it is therefore imperative that a doctor makes his 
name known in the hne in which he wishes to be employed ; that 
is to say, if he wishes to build up a private practice, he must be- 
come well acquainted with the people among whom he resides. 
Should he desire to make examinations for insurance companies, 
it is necessary that he cultivate the acquaintance of men who are 
in charge of these companies or the individual who is in charge of 
the department which requires his services. If he wants to exam- 

613 



614 SECURING APPOINTMENTS AS EXAMINER 

ine for a fraternal organization, he must pursue the same plan 
of putting his name forward among the class of people that go 
to make up these great organizations. Successful business men 
increase their business by advertising in the daily papers and in 
other ways, but as a physician is prohibited from getting his name 
before the public in this manner, he must use other methods which 
come within his creed. 

PAPERS ON MEDICAL SUBJECTS: The writing of 
papers for medical journals on subjects pertaining to the prac- 
tice of medicine and surgery, is one of the means whereby a phy- 
sician can bring himself into prominence among his own profes- 
sional associates, and this way is often adopted by a great many 
physicians to accomplish this purpose. All physicians are not 
capable, however, of writing original articles on medical or sur- 
gical subjects, but all physicians can report interesting cases 
which occur almost daily in their practice, — if they would only 
take the time and trouble. Doctors lose sight of the fact that 
many of their professional associates are pushing themselves for- 
ward in this manner; which is a proper and legitimate way. 

PAPERS FOR INSURANCE JOURNALS: If a physician 
decides that he desires to make examinations for an insurance 
company, one of the best ways that he can become known among 
these corporations, is to write for insurance journals on medical 
subjects pertaining to life, accident or health insurance and write 
these papers in such a way that any one who has not had a medi- 
cal education can read, understand and enjoy them. There are 
quite a number of insurance journals throughout the United 
States and almost without exception they would be willing and 
glad to accept an article on a medical subject, when that article 
is so written that all of their subscribers cannot only understand 
it, but derive benefit from it. It is imperative, however, that such 
a subject be considered in the plainest language possible and de- 
void of all medical terms. By writing for medical and insurance 
journals, a physician is able to bring his name more prominently 
before a large number of people than in any other way, and the 
more he writes, the more readable become his articles and a 
great number of people enjoy them, and gradually know the 
writer by reputation. 

INFLUENCE WITH MEDICAL DIRECTOR: Appoint- 
ments as examiner for an insurance company are often made be- 
cause the doctor is personally acquainted with the medical di- 
rector or other officer of the company. They are sometimes re- 



INFLUENCE WITH AGENT 615 

ceived when the medical director is familiar with writings of the 
doctor which he has probably read in different medical or insur- 
ance journals, as a medical director must not only read medical 
journals, but must also spend more or less time in going over in- 
surance pubHcations. The more influence a physician can bring 
to bear with the medical director, of a company or other home 
office official who has power, the quicker and easier will he se- 
cure an appointment as examiner. 

INFLUENCE WITH AGENT: Acquaintance with an 
agent of an insurance company or with the general agent who 
directly represents the company is desirable, as in many cases in- 
surance companies appoint examiners on the recommendation of 
their agents. It must be remembered, however, that a number of 
companies will not appoint a physician as exarniner when recom- 
mended by the agent; therefore, in attempting to obtain an ap- 
pointment from an insurance company, it is well to make in- 
quiries as to how the medical director views a recommendation 
from an agent for the appointment of a certain doctor as an ex- 
aminer. The agent himself usually knows how this subject is 
treated at the home office and can often give valuable information 
to a physician seeking an appointment. Many appointments se- 
cured by physicians as examiners for insurance companies are re- 
ceived through influence and whenever this method can be em- 
ployed, it is one of the most successful ones. It is therefore im- 
portant that doctors in attempting to secure an appointment, 
bring to bear all the influence they can in whatever manner pos- 
sible with the medical director or the one who has the power of 
appointing. 

WRITING MEDICAL DIRECTOR: When a physician is 
not acquainted with the medical director of an insurance company 
or any one in authority, he must use other means than influence 
in securing an appointment, and if he is located at a distace from 
the home office of a company, the only way that he can possibly 
get his name before the home office officials is by repeated let- 
ters in which he states his desire to represent the company as its 
medical examiner in the vicinity in which he resides. In attempt- 
ing to secure an appointment as examiner through the method of 
writing the medical director, it is necessary that a follow-up sys- 
tem be used for this purpose. The sending of one letter to a 
medical director requesting an appointment is considered about 
as much good as one advertisement in a newspaper on any sub- 
ject, — the value of which is practically nothing unless the adver- 



616 SECURING APPOINTMENTS AS EXAMINER 

tisement is followed up by the same one or changed repeatedly. 
It is therefore necessary when writing for an appointment to an 
insurance company that a number of letters be written and that 
each letter have a special object in view. This object of course, 
is the securing of an appointment but each letter must be worded 
differently and bring the purpose of the writer to the eyes of the 
medical director in another and entirely new way, if possible. 
When it is remembered that reports from physicians are required 
in their own handwriting, it can readily be seen that this writing 
should be the best that a physician can do; therefore, in writing 
letters to the home office for the purpose of securing appoint- 
ments, physicians should be very careful of the manner in which 
the letter is written and also its composition. If the writing is 
poor and read with difficulty, it is almost a foregone conclusion 
that the writer will not receive an appointment, as the medical 
director is required to read a number of reports daily and he can- 
not afford to spend much time in reading reports from physicians 
who are such poor writers that more than the usual time is taken 
in reading them. The wording of the letters should be short 
and to the point and convey as much information in a few lines 
as it is possible to give. With this idea in view, the following set 
of letters have been prepared and may be used by physicians for 
this purpose. It being borne in mind that alterations, additions 
and omissions should be used whenever necessary. Letter num- 
ber one represents the first letter of a series that can be sent to 
the home office of a company in an attempt by the doctor to se- 
cure an appointment as the examiner. 



190 

Insurance Co., 
(Address) 



4 



Gentlemen : — 

Please consider me an applicant for the position of medical 

examiner for your Company in this city. I am years old, 

a graduate of the Medical College in 

and have had years experience as resi- 
dent physician in the Hospital before commencing 

the practice of medicine. My habits are strictly correct and I can 
give you a number of references if desired. 

Trusting to receive a favorable reply, I am. 

Yours very truly. 



LETTERS TO MEDICAL DIRECTOR 617 

In the above it will be seen that the doctor writes a short let- 
ter, simply stating that he is desirous of being appointed as the 
examining physician of the company to which he writes, giving 
his age, college of graduation and years of experience, together 
with a few words about his habits and ability to furnish refer- 
ences. This letter is almost sure to bring a reply of some kind 
either from the medical director or from some other official of 
the company. This reply should be preserved and filed away as 
it indicates the person to whom in the future the following let- 
ters of the series must be forwarded. After waiting some weeks 
or months according to the desirability of the physician to be ap- 
pointed as the examiner, another letter is sent to the same com- 
pany and to the person who answered the first one. This second 
letter calls the attention of the company to the fact that the doc- 
tor has previously made an application for appointment and is 
still desirous of being considered should a vacancy occur; and can 
be written as per the following with some changes which may 
suggest themselves to the writer. 

190 

Dr Medical Director, 

Insurance Co., 

(Address) 

My dear Doctor: — • 

Some weeks ago I wrote you requesting an appointmnet as 
medical examiner, but as yet have not received an appointment. 
If you are already satisfactorily represented here, may I ask that 
my application be placed on file and favorably considered at the 
first opportunity? 

Thanking you for any courtesy extended and trusting to 
hear from you at your early convenience, I am. 

Very respectfully, 

After this letter has been sent and the reply received, it will 
be known if the official at the home office remembers the appli- 
cation of the doctor which was made some weeks or months pre- 
viously. If the application has been forgotten, the medical direc- 
tor may ask for some information concerning the applicant. In 
which case, the doctor Avho is trying to secure the appointment 
will know that he is making some progress, at least in getting his 
name before the proper officials: and if he does tiot yet roooivo an 
appointment or some encouragement, he can write with bonotit 



618 SECURING APPOINTMENTS AS EXAMINER 

to himself another letter to the company after several months 
have elapsed, and couched in the following or similar language. 

190 

Dr Medical Director, 

Insurance Co., 

(Address) ! 

My dear Doctor: — 

I wrote you some months ago requesting an appointment 
as medical examiner and was informed that you had no vacan- 
cies in this city. As vacation is approaching and many of our ph 
sicians are out of the city during the summer, I thought perhaps 
you might need a substitute and would permit me to serve you. 

Trusting to have an early reply and thanking you for any 
courtesy extended, I am, 

Respectfully, 

In the above letter it will be noticed the intention of the doc- 
tor is to keep his name constantly before the medical director, 
using any excuse that circumstances may warrant. This letter 
may bring a reply of only a few words stating that the company is 
well represented and has no need of the services of the applicant. 
Such a reply should not discourage the doctor as he can rest as 
sured that every letter that is dictated to him by the medical di 
rector has helped in bringing or keeping his name before thi 
ofificial and in time the medical director will know that such a 
doctor lives in such a locality and has been writing to him re- 
peatedly for an appointment as examiner. Not having yet re- 
ceived an appointment, the fourth letter or one in which another 
pretence is used for writing can be sent to the company. 

190 

Dr Medical Director, 

Insurance Co., 

(Address) 

My dear Doctor: — 

I beg to recall to your attention my letter of some months 
ago, requesting an appointment as medical examiner and to state 
that I am still an applicant for the position. If you have any in- 
tention of making a change in the near future, I should esteem 
it a favor if you will consider my application. 



I 



LETTERS TO MEDICAL DIRECTOR 619 

Thanking you for past courtesies and trusting to hear favor- 
ably, I am, 

Yours truly, 

Even this letter may not succeed in its mission but as before 
stated, the doctor is succeeding in getting his name better known 
at the home ofhce and this may at some future time serve him in 
good stead. The writer should not be daunted by refusals or in- 
ability to secure an appointment from the company, it being taken 
for granted that he has written to a number of them, and that 
all of them will not have been found to be satisfactorily repre- 
sented. It is therefore fair to assume that one or more appoint- 
ments have been secured and the following or fifth letter is sent 
to the home office of the company which has not as yet appointed 
the doctor as its examiner. 

190 

Dr Medical Director, 

Insurance Co., 

(Address) 

My dear Doctor: — 

I am again writing you in reference to an appointment as 
medical examiner and trust you will not consider me too insistent, 
but I very much desire such work and as I am making more or 
less of a specialty of insurance examining, I thought you might 
desire to avail yourself of my services. 

Thanking you for your uniform kindness in the past and 
trusting to have a favorable reply, I am, 

Respectfully yours, 

In the above letter it will be seen that the doctor informs the 
company that he is making more or less of a specialty of examin- 
ing for insurance companies, and that he still desires an appoint- 
ment from the company to which he is writing. This form of let- 
ter can be used and if desired, the doctor can name several com- 
panies of which he is the appointed examiner. 

If an appointment has not been received after writing all 
these letters, a physician should not become discouraged, but 
should continue to pound away at the insurance company by 
writing whenever he has an opportunity, as sooner or later a va- 
cancy with the company to which ho has Ihhmi writing will occur: 
and if he has previously kept his name hof(M-o the medical director. 



620 SECURING APPOINTMENTS AS EXAMINER 

he stands a very good chance, — all other things bemg equal, — of 
being appointed the examiner and if appointed, he should at once 
on receipt of the letter of appointment, write the following letter 
of thanks. 

190 

Dr. Medical Director, 

Insurance Co., 

(Address) 

My dear Doctor: — 

Your favor of the inst., stating that I had been ap- 
pointed an examiner for your company is received and I beg to 
thank you very much indeed for the honor conferred on me. It 
will be my intention and ambition to render the compan}^ the 
best services that I am capable of and I trust they may always be 
satisfactory. 

Again thanking you, I am. 

Yours very truly. 

This last letter requires little time, but by writing it, the 
medical director is assured that his new examiner is appreciative 
and again has the doctor succeeded in getting his name before 
his employer. 

PERSONAL ACQUAINTANCE: It is said by some men 
that all favors extended in business, are extended through per- 
sonal acquaintance or the desire of one party to help another, be- 
tween which bonds of friendship usually exist. Whether this is 
true or not, it is always to the advantage of a physician that he 
extend his acquaintance, not only himself knowing a number of 
people but what is better, having them know him by reputation 
and personal acquaintance. It is therefore desirable and to the 
advantage of every physician who expects to do insurance work, 
that he take every opportunity of meeting the medical directors 
of the various insurance companies of the United States. It is of 
little concern to him if he is an examiner for the company which 
is represented by. the medical director or not, but it is of course 
helpful to a physician if he is acquainted with the medical director 
of a company for which he has been appointed as examiner. 

For the purpose of knowing these men personally, it is often 
necessary that a physician visit the home ofhce of the companies 
to which he has made apphcation for appointment or may do so 
at some future time. It is realized that physicians in certain parts 



PERSONAL ACQUAINTANCE 621 

of the United States cannot become personally acquainted with 
home office officials, but physicians travel more or less, and dur- 
ing these times they should make every effort to become person- 
ally acquainted v^ith officials connected with the home office of an 
insurance company or fraternal organization. Not only should 
the acquaintance be made with the medical director, but also with 
any other officials, as there is no telling at what time some one 
may be able to recall the name of a doctor who has made a visit 
to the home office and thereby throw a certain amount of influ- 
ence in his favor. Physicians who live near the large cities and 
the home office of a number of insurance companies and fraternal 
.organizations, should make it a rule to visit these offices two or 
three times each year, thus becoming known to the officials and 
employees connected there. It might also be said that these 
.visits cannot be too frequent and neither can they when the doc- 
tor lives in the same city, or within a short distance of the office 
of the company which he represents or hopes to represent at 
some future time. If it is impossible to visit the home office of 
an insurance company, it should be remembered that the various 
;accident companies hold conventions throughout the year, and 
at these conventions the companies are represented by their 
highest officers; therefore, if a physician will attend these con- 
ventions he will soon become well known to a number of officials 
^connected with the home office force. This is also true of fra- 
ternal organizations, but in this case it is always necessary that 
the doctor be a member of a subordinate lodge of the fraternal 
society with which he hopes to become identified. 

Accident insurance companies have formed two associations 
]in the United States, the International Association of Accident 
jUnderwriters which meets once a year and usually sometime in 
July, and the Detroit Conference which meets semi-annually, first 
,in one city and then in another. If a physician desires to attend 
one of these conventions, he can usually secure an invitation 
ithrough a friend who is connected with a company represented or 
by means of the local agent, and when once secured, he can eas- 
ily get letters of introduction to the officials of one or more com- 
panies and at the convention which he may attend, he will quickly 
become acquainted with all the representatives of the different 
! companies. 

Every opportunity should be taken by a doctor to become 
better acquainted in a business or social way with his employers 
who are represented by officials from the home office of an in- 



622 SECURING APPOINTMENTS AS EXAMINER 

surance company or fraternal organization. A doctor shoul 
impress his personality upon the officials of the home office of any 
company of which he has been appointed as examiner. Therej 
are a number of ways of accomplishing this purpose. He ma^' 
do it by frequent calls at the office of the company and thereby 
become personally acquainted with a number of the employees 
or, if he lives at a distance and this method is impracticable, he 
can call attention to himself by the character of his reports which 
should be perfect in every way. A report which is of much value 
to an insurance company means that the examination has been, 
promptly made, all the questions have been answered in an in- 
telligent and concise manner, the writing is the best that the ex- 
aminer can do and is easily read and any additional informatior 
that may be of value to the company is included in the report 
Such a report is valuable to the company and the examiner aj 
well, because the examiner soon earns a reputation at the home 
office as being a good man and his personality thereby becomes 
impressed upon the employees. Some examiners become bet- 
ter known to the medical directors of the different companies by 
writing a short letter with each report, giving confidential infor- 
mation or other facts which they cannot put in the report proper. 
Other doctors have a few words to say on a prescription blank 
conveying additional information and attach this blank to the re- 
port. Any little method or peculiarity that is not distasteful to- 
the medical director or causes him to lose valuable time, will as- 
sist in accomplishing the aim desired. It is a standing joke in 
some offices that just as soon as a report comes from certain doc- 
tors, to ask if his prescription blank is attached to that report, or 
if a letter has been received in addition or a telephone message 
covering it. These little things may seem trivial, but at the same 
time an examiner who uses every means in his power to make his 
name better known at the home office, is the one who is known 
and recalled when an examination is desired or the name of a 
doctor requested by another company that wishes to make a new 
appointment and he is the one who receives the work or the ap- 
pointment in almost every case. 

After a physician has received an appointment as examiner, 
he must continue to keep his name and personality before the 
medical director and other officials of the company. If he does 
not, the appointment is merely an honorary one, for the reason 
that his name is lost among the large number of examiners who 



MUTUAL NEED 623 

work for the company and he therefore receives no examinations. 
He must continue to let the company know by every means in his 
power that he is the examiner and the one who wishes the exam- 
inations and by so doing he will usually be favored with them. 

MUTUAL NEED : Physicians desire and need the work 
that is furnished by insurance companies and these companies 
are just as desirous of knowing and appointing good physicians 
as their examiners in different sections of the United States. If 
a company has no examiner in a certain section, — even though it 
may not have any business there, — the medical director does not 
know how soon the agency force will commence writing business 
in that locality; therefore, he is always on the lookout for respon- 
sible and qualified physicians and is ready and willing to appoint 
them in any part of the country, and when the company starts to 
do business in that section, he has his examiners already ap- 
pointed and prepared to make examinations when called upon to 
do so. Physicians throughout the United States in requesting 
appointments as examiners not only benefit themselves, but also 
favor the different companies; and medical directors are always 
glad to receive letters asking for appointments, and usually they 
have what is known as a waiting Hst. This list is used for the pur- 
pose of keeping the names of physicians whose character and abil- 
ity have been investigated and who are thought, would prove to 
be good examiners. If a physician cannot secure an appointment 
as examiner for a company, he can generally get his name on this 
list and by frequently calling the attention of the medical director 
to the fact that he is waiting for an appointment, often secure it 
. when the first vacancy occurs. 

APPOINTMENTS: The medical director is the one in al- 

\ most all cases who has the power of appointing examiners, and he 

is the one whose acquaintance should first be cultivated and later 

on other members of the home office force if possible. A medical 

' director often appoints an examiner at the request of some other 

official of his company and therefore it is well to know any offf- 

cial. Appointments that are secured from insurance companies 

which are not doing business in a locality in which the doctor is 

located, while not valuable in a pecuniary way, arc very valuable 

'in assisting a doctor to receive other appointments, as the ma- 

' jority of companies in sending out a letter of application for ap- 

'ipointment as medical examiner, request the names of companies 

"for whom the physician is examiner. If a doctor has boon [\p- 

^ pointed examiner for one or more companies, lio can state in his 



624 SECURING APPOINTMENTS AS EXAMINER 

application that he is the examiner for certain companies even 
though he has never done any work for them. The company to 
which he is applying will probably not know if their competitor 
is doing business in that locality or not, and the fact that the doc- 
tor is an examiner for one or more companies carries much 
weight in securing another appointment. It is therefore advis- 
able that physicians get as many appointments as examiners for 
different insurance companies as is possible. When a doctor has 
been appointed as examiner for a fraternal organization, he stands 
in a different position in relation to insurance companies which 
usually regard a fraternal examiner as not as competent as he 
might be. This is undoubtedly an error in a great many cases, but 
does not alter the fact that such a feeling exists among the medi- 
cal directors of different insurance companies. If a doctor, in ap- 
plying for a position as examiner with an insurance company does 
not hold an appointment as examiner with another company, but 
does represent as examiner, one or more fraternal organizations, 
he will probably assist himself in stating this fact, rather than not 
making any mention of it, as by so doing he shows that he has 
had some experience in examining. j 

BUREAU OF INFORMATION: Accident insurance com.-j 
panics have a bureau to which is reported by every company a 
number of facts, and among these all companies report the names, 
of satisfactory examiners. Therefore, if a physician is an exam-j 
iner for an insurance company and has reason to believe that his 
work is satisfactory, it would be to his interest to write the com- 
pany requesting that his name be recommended to the bureau of 
information so that he may receive requests for examinations, 
from other companies. A number of companies send the names 
of their best examiners to this bureau, but whether they do so or 
not, it is to a doctor's advantage to make this request and later 
on, to know that it has been complied with. If his name is on 
this list, he is sure to receive examinations, and in many cases ap- 
pointments as examiner for other companies that he might not 
otherwise be able to secure. 



INDEX 



ABDOMEN 

abrasions, 143 

burns, 134 

contusions, 143 

dropsy of the, 503 

hysterical distention of, differential diag- 
nosis in peritonitis, 516 

incisions, 146 

lacerations, 146 

punctured wounds, 147 

scalds, 134 
Abdominal typhus, 493 

muscle, rheumatism of, differential diag- 
nosis in peritonitis, 516 

walls, incisions and lacerations of, 146 
Abdominalis, typhus, 493 

Ability to detect fraudulent claims (acci- 
dent), 603 
Abrasions of 

abdomen, 143 

arm, 201 

back, 158 

chest, 127 

elbow, 206 

eyelids, 80 

face, 70 

fingers, 213 

foot, 2^6 

forearm, 206 

hands, 213 

hip, 259 

leg, 267 
. male sexual organs and surrounding 
parts, 175 

neck, IIS 

scalp, 61 

shoulder, 201 

thigh, 259 

toes, 276 

wrist, 213 
Abscess of brain, 100 

as complication in concussion of brain, 104 

as complication in cholera, 506 

differential diagnosis in acute cerebral lep- 
tomeningitis, 348 

cerebral, 100 

ear as complication in pharyngitis, 413 

heart, 379 

hepatic, complication in acute dysentery, 
434 

iliac, 429 

ischio-rectal, 192 

larynx as complication, 125 

liver in differential diagnosis in carcinoma 
of the liver, 456 

liver, 451 

liver as complication in proctitis, 448 

lung, 389 

lung as complication in punctured wound 
of the chest, 132 

middle ear, 92 

middle ear as complication in acute ton- 
silitis, 423 

middle ear, acute, as complication in acute 
nasal catarrh, 398 

as complication in incisions and lacerations 
of neck, 119 



625 



Abscess, palmar, 221 

palmar, complication in abrasions and con- 
tusions of wrist, hands and fingers, 214 

perinephritic, differential diagnosis, 471 

perineal, complication in incisions and 
lacerations of male sexual organs, 177 

perineum, 196 

perityphilitic, 429 

retropharyngeal, differential diagnosis in 
pharyngitis, 413 

scalp, as complication in contusions of 
scalp, 64 
Accidents as complication in epilepsy, 342 
Accident claims, adjusting, 597 

claims, adjusting, time of, 2 

definition of, 598 

demand foi, 2 

examinations, 2Z 

examination blank, 29. 

insurance physicians welcome, 4. 

notice of, in accident policies, 53 

policies, 47 
Accidental death in accident policies, 47 

rashes m differential diagnosis in scarlet 
fever, 490 
Accommodating, 13 

Accumulations in accident policies, 51 
Acetanilid poisoning, 574 
Acetate lead, poisoning, 542 
Acid, acetic poisoning, 555 

burns as complication in burns and scalds 
of the leg, 275 

carbolic, 534 

gas poisoning, carbonic, 590 

hydrochloric, 538 

hydrocyanic, 559 

muriatic, 538 

nitric, 547 

nitric, diff'erential diagnosis in hydro- 
chloric acid, 538 

of sugar, 571 

oxalic, 571 

phenic, 534 

potassium oxalate, 572 

prussic, 539 

Scheele's, 539 

sulphuric, 552 

differential diagnosis in hydrochloric 
acid. 538 
Aconite poisoning, 556 
Aconitum napellus, 550' 
Acquaintance, increasing, 5 

personal, 620 
Acromio-clavicular articulation, sprains, 22^ 

clavicular articulation, dislocation, 2Z\ 
Acromion process, fracture of, complication, 

225 
Activity, impaired mental, sequelx in sun- 
stroke, 366 , 
Acute abscess of the middle ear complica- 
tion, 39S 
Acute anterior polio-myelitis, differential 

diagnosis in acute myelitis, 351 

articular rheumatism, 517 

articular rheutnatism in differential diag- 
nosis in sprains of the acromio-clavic- 
ular and shoulder joints. r.'3 



626 



INDEX 



Acute articular rheumatism in differential 
diagnosis in dislocation of ankle, 301 
articular^ rheumatism in differential diag- 
nosis in sprains of ankle joint, 300 
articular rheumatism in differential diag- 
nosis in dengue, 479 
articular rheumatism in differential diag- 
nosis in gout, 512 
articular rheumatism in differential diag- 
nosis in dislocations of knee joint, 295 
articular rheumatism in differential diag- 
nosis in sprains of knee joint, 291 
articular rheumatism in differential diag- 
nosis in sprains of wrist joint, 234 
Bright's disease. 463 
bronchial catarrh, 395 
bronchitis, 395 

as complication in influenza, 496 
catarrhal bronchitis, 395 

enteritis, differential diagnosis in acute 

dysentery, 433 
laryngitis, 407 
pharyngitis, 413 
cerebral leptomeningitis, 347 
coryza, 397 

croupous nephritis, 463 
desquamative nephritis, 463 
dysentery, 433 
encephalitis, 100 
endocarditis, 373 
endocarditis in differential diagnosis in 

pericarditis, 382 
enteritis, differential diagnosis in perito- 
nitis, 516 
Acute gastric catarrh, 439 
gastritis, 439 

gastritis, differential diagnosis in perito- 
nitis, 516 
hemorrhagic pancreatitis, differential diag- 
nosis, in intestinal obstruction, 446 
hepatitis, 451. 
indigestion, 439 
inflammation of the kidneys, complication 

in acute toxic gastritis, 441 
meningitis, 347 

meningitis, differential diagnosis abscess of 
brain, loi 
Acute miliary tuberculosis, differential diag- 
nosis in acute bronchitis, 395 
miliary tuberculosis in differential diag- 
nosis in typhoid fever, 404 
miliary tuberculosis in differential diag- 
nosis in pulmonary tuberculosis, 425 
sore-throat, 413 
myelitis, 350 
myocarditis, 379 
nasal catarrh, 397 
nephritis, 463 

complication in cholera, 506 
parenchvmatous nephritis, 463 
pericarditis, 381 
periostitis, differential diagnosis in acute 

articular rheumatism, 519 
peritonitis, 515 
pharyngitis, 413 
prostatitis, 194 
pulmonary tuberculosis, 419 
rheumatoid arthritis, 518 
rhinitis, 397 
simple endocarditis, differential diagnosis 

in acute myelitis, 351 
spinal meningitis, differential diagnosis in 

acute myelitis, 351 
synovitis, complication in sprains of ^ the 
acromio-clavicular and shoulder joints, 
224 
tonsilitis, 422 
tonsilitis in differential diagnosis in 

pharyngitis, 413 
tonsilitis in differential diagnosis in scar- 
let fever, 490 
toxic gastritis, 441 



Acute toxic gastro-enteritis, differential diag- 
nosis in cholera, 506 
tuberculosis in differential diagnosis in 

catarrhal pneumonia, 415 
tuberculosis of the lungs, as complication 
in acute bronchitis, 396 
Acute tuberculous peritonitis, differential 
diagnosis in appendicitis, 430 
tubular nephritis, 463 
ulcerative endocarditis, 496 
i^ellow atrophy of the liver, in differential 

diagnosis in phosphorus, 551 
yellow atrophy of the liver in differential 
diagnosis in yellow fever, 501 
Addison's disease, differential diagnosis in 

catarrhal jaundice, 460 
Additional fees in court trials, 4 
Adenitis, tuberculous, differential diagnosis 
in abrasions and contusions of neck, 116 
Adhesive pericarditis, 381 
Adjusting, 6 

accident claims, 597 
health claims, 605 
manner of, 608 
liability claims, 610 
Adjustment, early (accident), 599 
health, 607 

manner of (accident), 600 
manner of (health), 608 
Advanced payments in accident policies, 52 
Age, 10 

height and weight, 16 
Agent, influence with, 615 . 

relations with, 15 
Ague, 480 

Air in pleural cavit5% 420 
Albuminuria, differential diagnosis, 463 

chronic, 465 
Alcohol, methyl, 576 
phenylic, 534 
wood, 576 
Alcoholic coma, dift'erential diagnosis, con- 
cussion of brain, 103 
differential diagnosis in apoplexy, 340 
paralysis, 358 
Alkali, volatile, 578 
Alkalies, caustic, 582 

fixed, 582 
Alvin flux, 436 
Amebic _ dysentery, 433 
Ammonia poisoning, 578 

water, 578 
Amputation through the carpus, 253 
. femur, 311 
foot, 323 
forearm, 250 
leg, 317 

phalanges (fingers), 257 
thigh, 311 . _ 

toes, 325 

upper extremity, 245 
Amygdalitis, 422 

Amyotrophic lateral sclerosis, 344 
Anemia, 371 

in differential diagnosis in leucocythemia, 

378 
splenica, 377 
Angina 

catarrhalis, 413 

membranous, 399 

pectoris, 372 

pectoris, differential diagnosis in gastralgia, 

438 
simple, 413 . . 

Angina-pseudo, dift'erential diagnosis in an- 
gina pectoris, 372 
Angiocholitis, catarrhal, 460 
Ankle, dislocation of, 301 
fractures involving the, 319 
punctured wounds of. 272 
sprains of, 299 



INDEX 



627 



Ankylosis as complication in dislocation of 
elbow joint, 233 
as complication in sprains of the wrist 
joint, 235 
Anthrax, 328 
Ano, fistula in, 184 
Anterior poliomyelitis, acute, differential 

diagnosis, acuti myelitis, 351 
Antimony, 528 
butter of, 528 
tartrate, 52S 

tartrated or tartarized, 52S 
Antipyrin, 574 
Anxiety, 3 
Apoplexy, cerebral, 339 

as complication in acute interstitial ne- 
phritis, 468 
complication, chronic interstitial nephritis, 

468 
coma, due to, 103 

differential diagnosis in pernicious malarial 
fever, 485 
Appearance, personal, 9 
Appendicitis, 429 

gangrenous, complication in appendicitis, 

.430 
differential diagnosis ia intestinal ob- 
struction, 446 
differential diagnosis, ptomaine poisoning, 

583 
differential diagnosis in renal calculi, 474 
suppurative, 429 
Appointments, 623 
Aqua fortis, 547 
Arachnitis, 347 
Arm, 

abrasions, 201 
burns, 205 
contusions, 201 
incisions, 202 
lacerations, 202 
punctured wounds, 203 
scalds, 205 
sprains of the, 223 
Arsenic, 531 

Arsenical poisoning, differential diagnosis 
in antimony, 529 
differential diagnosis in mercury, 545 
Arsenite, copper, 531 
Arteries or nerves, complication, fractures 

of humerus, 244 
Arthritis, acute rheumatoid, differential diag- 
nosis in acute articular rheumatism, 518 
gonorrheal, as complication in gonorrhea, 

186 
gonorrheal, differential diagnosis in sprains 

of knee joint, 292 
rheumatoid, differential diagnosis in gout, 

512 
rheumatoid, differential diagnosis in sprains 

of hands and fingers, 238 
septic, differential diagnosis in acute ar- 
ticular rheumatism, 518 
suppurative, differential diagnosis in 

sprains of elbow. joint, 230 
tuberculous, differential diagnosis in dis- 
location of the ankle, 302 
Articular rheumatism, acute, 517 

rheumatism, acute, differential diagnosis in 
sprains of the acromio-clavicular and 
shoulder joints, 223 
rheumatism, acute, differential diagnosis in 

dislocation of ankle. 301 
rheumatism, acute, differential diagnosis in 

sprains of ankle joint, 300 
rheumatism, acute, diflferential diagTiosis in 

dengue, 479 ,.^ . , ^. 

rheumatism, acute, differential diagnosis in 

gout, 512 
rheumatism, acute, differential diagnosis in 
dislocations of knee joTnt. 295 



Articular rheumatism, acute, differential 
diagnosis in sprains of knee joint, 291 
rheumatism, acute, differential diagnosis in 
sprains of wrist joint, 234 
Articulation, 

acromio-clavicular, dislocation of, 224 

sprains of the, 22.Z 
pubic, sprains of the, 282 
sacro-iliac, sprains of the, 282 
sterno-clavicular, dislocation of the, 136 
temporo-maxillary, dislocation of, 105 
Artisans' cramp, 359 
Ascites, ^03 
Asiatic cholera, 504 

differential diagnosis in antimony, 530 
differential diagnosis in cholera morbus, 
432 
Aspiration pneumonia, complication in punc- 
tured wounds of neck, 121 
Asthma, 390 

cardiac or renal, differential diagnosis, 392 
essential, 390 
hay, 393 

hay, differential diagnosis in asthma, 392 
spasmodic, 390 

spasmodic, differential diagnosis in emphy- 
sema, 402 
A stroke, 3 
Ataxia, locomotor, 343 

differential diagnosis in multiple neuritis, 

.359 
differential diagnosis in neuralgia, 353 
Atrophy, chronic spinal muscular, 344 

idiopathic muscular, differential diagnosis 

in progressive muscular, 345 
liver, acute yellow, differential diagnosis in 

phosphorus, 551 
liver, acute yellow, differential diagnosis in 

yellow fever, 501 
progressive muscular, 344 
progressive muscular, differential diagnosis 

in muscular rheumatism, 521 
retina, as complication in diabetes mellitus, 

508 
testes, as complication in incisions and 
lacerations of male sexual organs. 17/ 
Atropin poisoning, differential diagnosis in 

cocaine, 560 
Attending physician, examination with (ac- 
cident), 25 
examination with (health), 31 
examination without (accident), 24 
examination without (health). 31 
no criticism of (accident), 28 
no criticism of (hcaltii). 34 
Attention, medical, in accident policies, 54 
Auricle, injuries of. 91 
Auris hematoma, comjilication in injuries of 

the auricle, 91 
Autumnal catarrh. 393 

fever, 493 
Autumnale colchicum, 561 

r.ACILLARV dvscnterv, 433 
Back, 

abrasions. 158 

lurns, 162 

contusions, 158 

incisions, 160 

lacerations, 160 

punctured wounds. 161 

scalds. 162 

sprains. 165 

dilYcrential diajiuosis in nuiscular rheu- 
matism. 5.'o 
lUxoniing well known. 61.5 
Bed-sores, complication in fractures and dis- 
locations of vertobr.T, 170 
Belladonna poisoning. 558 
iicll's pnlsy. 361 

l^enetieiary insurance in aooiilent policies, sj 
In-notits, eombiration, in accident policies. 50 



628 



INDEX 



Benign neoplasms, differential diagnosis in 

cancer of penis or testes, 179 
Beri-beri, 358 

Bile ducts, catarrh of the, 460 
Biliarj' calculi, 453 

colic, differential diagnosis in eastralgia, 

438 
colic, differential diagnosis in peritonitis, 
. . 516 
Bilious cholera, 431 
fever, 439-482 
headache, 346 
malignant fever, 500 
remittent fever, 482 
tj'phoid fever, 487 
Biliousness, 459 
Bills and fees. 21 
Bismuth, 533 

smallpox, 524 
Black vomit, 500 

Bladder, cancer of. the walls of the, com- 
plication, 470 
catarrh of the, 469 

distention of the, differential diagnosis, 503 
gall, wounds of, 149 
inflammation of the, 469 
rupture of the, complication in abrasions 

and contusions of abdomen, 144 
walls, tuberculosis of the, complication, 470 
wounds, 150 
Blank, examination (accident). 29 
examination (health), 33 
examination (liability). 41 
explanation of (liability), 42-45 
Bleeding piles, 188 
Blepharitis marginalis. differential diagnosis 

in burns and scalds of eyelids, 84 
Blind headache, 346 

Blood and urine, extravasation of, complica- 
tion in incisions and lacerations of male 
sexual organs, 177 
vessels, injurj^ to, as cottiplication in dis- 
location of elbow joint, 232 
vessels, injury- to, as complication in dis- 
location of shoulder joint, 228 
white, 377 
white cell, 377 
Bloody flux, 433 
Blue rocket, 556 
stone. 536 
vitriol. 536 
Boil, 327 

as complication in diabetes mellitus. 508 
as complication in contusions of scalp, 64 
Bone felon, 332 

hyoid, fracture of. complication in abra- 
sions and contusions of neck, 117 
Bones, carpal, fracture of. 231 

fractured, as complication, punctured 

wounds, elbow, 210 
fractures of, as complications, dislocations, 

elbow joint. 232 
inferior maxillary, fracture of, 112 
malar, fracture of, 109 
meta-carpal, fracture of, 254 
nasal, fracture of, 107 
Bowels, inflammation of, 435 

obstruction of, 445 
Brain, abscess of the, 100 

differential diagnosis in acute cerebral lep- 
tomeningitis, 348 
concussion of, 102 

as complication in fracture of malar 

bones, no 
as complication in fracture of superior 
maxillary', in 
Break-bone fever, 479 
Breast-pang. 272 
Bright's disease, acute, 463 
chronic, 463-467 

as complication in angina pectoris, 373 
as complication in diabetes mellitus, 508 



Bright's disease, differential diagnosis in con- 
tusions of face, 73 
Bronchial asthma, 390 
catarrh, 393 
catarrh, acute, 393 
hemorrhage, 403 
Bronchitis, acute, 393 

acute, as complication in influenza, 406 

acute catarrhal, 395 

capillary, 414 

capillar}-, as complication in haj' asthma, 

393. 
chronic, differential diagnosis in emphy- 
sema, 402 
as complication in congestion of the lungs, 

409 
as complication in incisions and lacerations 

of neck, 120 
as complication in chronic interstitial ne- 
phritis, 468 
dilTereutial diagnosis in catarrhal pneu- 
monia, 415 
as complication in acute articular rheuma- 
tism, 319 
Bronchopneumonia, 414 

as complication in measles, 487 
as complication in incisions and lacerations 
of neck, 120 
Broncho-pulmonary hemorrhage, 403 
Brcnchorrhagia, 403 
Bureau of information, 624 
Burns, 

abdomen, 134 

acid as complication, burns and scalds of 

leg, 275 
arm, 205 
back, 162 
chest, 134 
elbow. 211 
eyelids, 83 
face, 77 
fingers. 220 
foot, 281 
forearm, 211 
hands, 220 
hip, 266 
leg. 275 
neck, 122 
scalp, 68 
shoulder, 203 
thigh, 266 
toes, 281 
wrist, 220 
Butter of antimony, 528 

CACHEXIA, chronic malarial, complication 
in pernicious malarial fever, 483 
malarial, sequelae in remittent fever, 483 
Calculi, biliary, 433 
hepatic, 433 
renal, 473 
Calculous pyelitis, differential diagnosis, 472 
Camp fever, 498 

Cancellation in accident policies, 54 
Cancer, gastric, differential diagnosis in gas- 
tralgia, 438 
hepatic, 456 
liver, 436 
differential diagnosis in abscess of the 

liver, 431 
penis and testes, 178 
stomach, differential diagnosis in gastric 

ulcer, 444 
walls of bladder,_ complication, 470 
Cantharides poisoning, -79 
Capillary bronchitis, 414 

as complication in hay asthma, 393 
Capitis, eczema, differential diagnosis in 

abrasions of scalp, 62 
Carbolic acid, 534 ,.„ . , .. 

Capsular fractures, extra, differential diag- 
nosis, dislocation of hip joint, 288 



INDEX 



629 



Carbon dioxide, 590 

monoxid, 592 
Carbonate lead poisoning, 542 
Carbonic acid gas poisoning, 590 

oxid gas poisoning, 592 
Carbiincle, 328 

differential diagnosis in furunculus, yzj 
as complication in diabetes mellitus, 508 
Carcinoma of liver, 456 

Cardiac or renal asthma, differential diag- 
nosis in asthma, 392 
Cardialgia, 437 
Carditis, 379 
Cardio-sclerosis, 379 

Caries of vertebrae, sequelae, sprains of 
back, 167 
differential diagnosis, concussion of spinal 
cord, 174 
Carpal bones, fracture of, 251 

meta, fracture of, 254 
Carpus, amputations through the, 253 

fractures of, differential diagnosis in frac- 
tures of carpal bones, 252 
Cartilage, xiphoid, complication in abrasions 

and contusions of abdomen, 145 
Cartilages, costal, dislocations of, 142 

semi-lunar, dislocation of, 298 
Catarrh, acute bronchial, 395 
acute gastric, 439 
acute nasal. 397 
autumnal, 393 
bile ducts, 460 
bladder, 469 
bronchial, 395 
epidemic, 405 
gastro-intestinal, complication in measles, 

487. 
intestinal, 435 
rectum, 44 S 
venereal, 186 
Catarrhal angiocholitis, 460 
bronchitis, acvite, 395 

conjunctivitis, differential diagnosis in con- 
junctivitis, 88 
dysentery, 433 

enteritis, 435 ... 

enteritis, acute, differential diagnosis in 

acute dysentery, 433 . 

enteritis, differential diagnosis in typhoid 

fever, 496 
fever, 405 
hepatitis, 460 
jaundice, 460 

jaundice, differential diagnosis m conges- 
tion of the liver, 459 
laryngitis, acute, 407 
nephritis, chronic, 465 

differential diagnosis, intestinal obstruc- 
tion, \\(i 
pharyngitis, acute, 413 
pneumonia, 414 ,. . . 

pneumonia, differential diagnosis in acute 

bronchitis, 395 
tonsilitis, 413 
Catarrhalis angina. 413 
Caustic alkalies, 582 
Cavity, pleural, air in, 420 
Cephalic tetanus, 367 
Cephalodynia, 520 _ _ 

differential diagnosis in muscular rh'-.una- 
tism, 521 
Cerebral abscess, 100 

apoplexy, 339 . , ,. • . , ,.- 

disease, differential diagnosis in acute gas- 
tric catarrh, 440 
fever, 347 
hemorrhage. ^39 
leptomeningitis, acute. 34/ 
symptoms in typhoid fever. .htl.Montuil 
diagnosis in acute cerebral U-ptonu-nm- 
gitis. 348 
Cerebro-spinal fever. 47 7 



Cerebro-^spinal meningitis, differential diag- 
nosis in typhus fever, 499 
meningitis, complication in spinal menin- 
gitis, 36s 
Cerebellum disease, differential diagnosis in 

locomotor ataxia, 343 
Ceruse, 542 
Cervico-brachial neuralgia, 352 

occipital neuralgia, >,^z 
Change of occupation in accident policies, 52 
Chancre, complication in gonorrhea, 187 
Chancroid, complication in gonorrhea, 187 
Charcot's joint, dift'erential diagnosis in con- 
tusions of knee joint, 261 
Chest, 

abrasions, 127 
burns, 134 
Cold on the, 395 
contusions, 127 
incisions, 129 
lacerations, 129 
punctured wounds, 130 
scalds, 134 
Chills, congestive, 484 

and fever, 480 
Chiragra, 511 
Chloral, 584 

Chlorosis, differential diagnosis, 460 
Cholecystitis, differential diagnosis in appen- 
dicitis, 429 
Cholelithiasis, 453 

differential diagnosis, gastric ulcer, 444 
Cholera, 504 
Asiatic, 504 
Asiatic, differential diagnosis in antimony, 

530 
Asiatic, differential diagnosis in cholera 

morbus, 432 
bilious, 431 
English, 431 
epidemic, 504 
malignant, 504 
morbus, 431 
morbus, dift'erential diagnosis in cholera, 

506 
differential diagnosis in pernicious malarial 

fever, 485 
dift'erential diagnosis in mushroom poison- 
ing, 566 
nostras, 431 
spasmodic, 504 
sporadic, 431 
Chronic albuminuria. 465 

albuminuria, dift'erential diagnosis in 

chronic interstitial nephritis, 467 
Bright's disease, 465-467. 
bronchitis, dift'erential diagnosis in emphy- 
sema, 402 
carditis. 379 
catarrhal nephritis, 465 
croupous nephritis. 465 
cystitis, complication in enlargement of 

prostate gland. 194 
cystitis, complication in fractures and dis- 
locations of the vertebra?, 170 
endocarditis, 3S5 
gastric ulcer. 443 
gastritis, differential diagnosis in gastric 

ulcer, 444 
interstitial myocarditis, 379 
interstitial nephritis. 467 
lead poisoning, differential diagnosis in 

occupation neurosis. 360 
malarial cachexia, complication in perni- 
cious malarial fever. 485 
myelitis, dift'erential diagnosis in locomo- 
tor ataxia. 344 
myocanlftis. 370 
nephritis. 465 

opium poisoning. ditYereiitial diagnosis in 
cocaine. 560 



63U 



INDEX 



Chronic parenchymatous nephritis, 465 
pericarditis, 381 
peritonitis, differential diagnosis in ascites, 

peritonitis, differential diagnosis in 

cirrhosis of liver, 45S 
phthisis, 424 
poliomyelitis, 344 
prostatitis, 194 
spinal muscular atrophy, 344 
tubular nephritis, 465 
ulcer, 335 

ulcerative phthisis, 424 
valvular disease, 3S5 
Circumscribed suppuration of the lung, 389 
Cirrhosis of the Ifver, 457 

dift'erential diagnosis in carcinoma of the 
liver, 456 
Claimant, cross-examination of, 18 
Claims, ability to detect fraudulent (acci- 
dent), 603 
accident, adjusting, 597 
adjusting accident, 597 
adjusting health, manner of, 608 
adjusting liability, 610 
fraudulent (health), 609 

dift'erential diagnosis in incisions and 

lacerations of the leg, 271 
differential diagnosis in abrasions of 

scalp, 61 
in neurasthenia, 355 - 
health, adjusting, 605 
liabilitj-, adjusting, 610 
Clap, 186 

Clavicle, fracture of the, 138 
Coal gas poisoning, 592 
Cocaine poisoning, 559 
Colchicum poisoning, 561 

autumnale, 561 
Cold on the chest, 395 
in the head, 397 
rose, 393 

exposure to, dift'erential diagnosis in facial 
paralysis, 362 
Colles' fracture, 249 

dift'erential diagnosis in dislocation of v/rist 
joint, 236 
Colic, biliarj% dift'erential diagnosis in gas- 
tralgia, 43S 
biliarv, differential diagnosis in peritonitis, 

■ dift'erential diagnosis in renal calculi, 474 

hepatic, 453 

hepatic, differential diagnosis in intestinal 
obstruction, 446 

intestinal, differential diagnosis in chole- 
lithiasis, 455 

renal, 473 

renal dift'erential diagnosis in appendici- 
tis, 429 

renal differential diagnosis in cholelithiasis, 

455 . . 

renal difterential diagnosis in gastralgia, 

438 

renal differential diagnosis m intestmaJ ob- 
struction, 446 
renal differential diagnosis in peritonitis, 

516 
stomach, 437 
Colitis, 433 

ulcerative, 433 
Collapse of the lungs, complication in abra- 
sions and contusions of chest. 128 
sequelae in whooping cough, 427 
Columbian or colonial spirit, 576 
Column, spinal, softening of, sequelae in 
sprains of back, 167 
vertebral, fractures and dislocations of, 
complication in sprains of back, 167 
Coma, 

alcoholic, differential diagnosis in apo- 
plexy, 340 



Coma, alcoholic, dift'erential diagnosis in con- 
cussion of the brain, 103 
diabetic, complication in diabetes mellitus, 

dift'erential diagnosis in chloral, 585 

brain, 103 
differential diagnosis in opium and mor- 
phine, 570 
differential diagnosis in sun-stroke, 366 
due to apoplexj-, 103 
uremic, 475 
uremic, differential diagnosis in apoplexy, 

340 
uremic, differential diagnosis in concussion 
of the brain, 103 
Combination benefits in accident policies, 50 

policies (health), 57 
Compan}- requirements (accident), 2j 

requirements (health), 33 
Complete dislocations, complication in sprains 
of knee joint, 294 
fractures, as complication in punctured 
wounds of leg, 273 
Compensation, 7 

Compound fractures as complication in frac- 
tures of pelvis, 306 
fractures, complication in fractures of car- 
pal bones, 252 
dislocations, as a complication in disloca- 
tion of shoulder joint, 228 
fractures, as complication in fracture of su- 
perior maxillary, 1 1 1 
Concentrated lye, poisoning by, 582 
Conciseness, 15 

Concussion as complication in fracture of 
the malar bones, no 
brain, 102 

brain, as complication in fracture of su- 
perior maxillar}-, in 
spinal cord, 171 

spine, as complication, sprains of the back, 
167 
Confluent smallpox, 524 

Congenital dislocations, dift'erential diag- 
nosis in dislocation of hip joint, 289 
Congestion, hypostatic, 409 
spinal, 346 
kidneys, 463 

complication in acute tonsilitis, 423 
liver, 459 
lungs, 409 
Congestive chill, 484 

fever, 484 
Conjunctivitis. 87 

catarrhal, differential diagnosis in conjunc 

tivitis, 88 
diphtheritic, 89 
follicular, 89 
gonorrheal, 88 
granular, 89 
mild, complication in acute nasal catarrh 

398 
phlyctenular, differential diagnosis in con 

junctivitis. 89 
trachoma, 89 
Consumption, pulmonar}*, 424 
Contagious fever, 405-498 
Continued fever, simple, 492 
Contracted kidney, 467 
Contusions of 
abdomen, 143 
arm, 201 
back, 1 58 
chest. 127 
elbow, 206 
eyelids, So 
face, 72 
fingers, 213 
foot, 276 
forearm, 206 
hands, 213 
hip, 259 



I 



INDEX 



631 



Contusions, knee loint, 260 

leg, z^j 

male sexual organs and surrounding parts, 
175 

neck, IIS 

scalp, 63 

shoulder, 201 

thigh, 259 

toes, 276 
^^wrist, 213 
Convulsions, 341 

uremic, 475 
Copper, arsenite, 531 

poisoning, 536 

differential diagnosis in phosphorus, 551 
Cord, spinal, concussion of, 171 

hemorrhage involving the, differential diag- 
nosis in .acute myelitis, 351 

spinal, softening of the, 350 
Cornea, ulcers of the, 85 
Coryza, acute, 397 
Corrosive sublimate, 544 
Costal cartilages, dislocations of, 142 
Cough, hooping, 427 

whooping, 427 
Coup-de-soleil, 365 
Court trials, additional fees in, 4 
Coxalgia, differential diagnosis in sciatica, z^7> 
Cramp, artisans', etc., 359 
Creosote poisoning, 534 
Criticism of attending physician (accident), 28 

health, 34 

of treatment (liability), 46 
Cross-examination of claimant, 18 
Croup, membranous, 399 

Croupous laryngitis, differential diagnosis in 
acute catarrhal laryngitis, 408 

nephritis, acute, 463 

nephritis, chronic, 465 

pneumonia, 416 

pneumonia, as complication in pleuritis, 411 

pneumonia, differential diagnosis in ca- 
tarrhal pneumonia, 415 

pneumonia, differential diagnosis in acute 
bronchitis, 395 
Cystitis, 469 

chronic, as complication in enlargement of 
prostate gland, 194 _ 

chronic, complication in fractures and dis- 
locations of vertebrae, 170 

complication in injury to the male urethra, 
196 

differential diagnosis in pyelitis, 47 1_ 
Cysts, hydatid, differential diagnosis in ab- 
scess of li-ver, 451 

DACTYLITIS, syphilitic, differential diag- 
nosis, 238 
Dancers' cramp, 359 
Dandy fever, 479 
Deadly night-shade, 558 
Death, accidental, 47 

indemnity, special in accident policies, 51 
Definition of accident, 598 

disease, 606 
Deformity, differential diagnosis in disloca- 
tion of sterno-clavicular articulation, 137 

sequelae in burns and scalds of back, 164 
Degenerative neuritis, 358 
Delirium tremens, differential diagnosis in 

acute cerebral leptomeningitis, 34S 
Deltoid muscle, paralysis of, differential 

diagnosis, 227 
Demand for examinations, 2 
Dengue, 479 ,. . . , ^ , 

differential diagnosis in scarlet fever, 400 

differential diagnosis in yello\y fever, 500 
Depressed fracture in differential diagnosis, 

contusions of scalp, 64 
Dermatitis, erysipelatous, 500 

venenata. 56:; 
Desquamative nephritis, aoiite, 463 



Diabetes insipidus, differential diagnosis, 507 

mellitus, 507 
Diabetic coma, complication in diabetes mel- 
litus, 508 
Diagnosis and prognosis (accident), 28 

health, 36 

differential, ability to make, 17 

differential (health), 609 

and prognosis, 6 
Diaphragm, the, 149 

opening in, as complication in punctured 
wounds of chest, 132 
Diarrhea, 435-436 
Diffuse myelitis, 350 

nephritis, 467 

peritonitis, complication in appendicitis, 
430 
Dilatation of the heart, 375 

heart, differential diagnosis in pericarditis, 
382 

right ventricle, sequelae in asthma, 392 

stomach, differential diagnosis, pneumotho- 
rax, 421 
Dioxid, carbon, poisoning, 592 
Diphtheria, 399 

differential diagnosis in acute tonsilitis, 423 

differential diagnosis in pharyneitis, 413 

differential diagnosis in scarlet fever, 490 
Diphtheritic conjunctivitis, differential diag- 
nosis, conjunctivitis, 89 

laryngitis, as complication in acute ca- 
tarrhal laryngitis, 4o8_ 

paralysis, post, sequelae in diphtheria, 401 
Director, medical, influence with, 614 

writing, medical, 615 
Disability, indemnity for total, in accident 
policies, 48 

indemnity for partial in accident policies, 
49 

partial indemnity for total, in health poli- 
cies, 59 

permanent, in health policies, 57 

policy, general, health, 56 

total in health policies, 38 
Disease, acute Eright's, 463 

Addison's, dift'ereiitial diagnosis, catarrhal 
jaundice, 460 

Bright's, as complication in angina pec- 
toris, Z7Z 

Bright's, as complication in diabetes mel- 
litus, 508 

Bright's, differential diagnosis in contu- 
sions of face, 71 

cerebellum, differential diagnosis iii loco- 
motor ataxia, 343 

cerebral, differential diagnosis in acute gas- 
tric catarrh. 440 

chronic Bright's, 465-467 

chronic valvular. 3S5 

definition of, 606 

of elbow joint, difl'erential diagnosis. 230 

Fallopian tubes, 4J0 

heart, valvular. 385 

hip joint, ditYorontial diagnosis in disloca- 
tion of hip, r88 
differential diagnosis in appendicitis, 430 

liver, lungs, heart, kidneys, as complica* 
tion in ascites, 504 

lungs, as conii)lication in emphysema. 40J 

mastoid, differential diagnosis, abscess of 
brain, loi 

middle oar, ditTercntial diagnosis in facial 
paralysis. 36J 

organic, of the heart, oomplioation. 468 
difforontial diagr.osis in sprains of wrist 
joint, 234 

ovaries, dilYerontial diagnosis in appenvlici- 
tis. 420 

testicle, tuberculous, differential diagnosis 
in epididymitis and orchitis. iSj 

tuberculous, oomplioation in fractures in- 
volving ankle joint. ,izo 



632 



INDEX 



Disease, tuberculous, acute, differential diag- 
nosis in sprains of _ the ankle, 299 

tuberculous, complication in abrasions and 
contusions of hip and thigh, 259 

tuberculous, differential diagnosis in dislo- 
cations of the knee joint, 295 

tuberculous, differential diagnosis, sprains 
of knee joint, 293 

urethral, complication in epididymitis and 
orchitis, 182 _ 

venereal, complication in cystitis, 470 

venereal, complication in suppuration of 
the inguinal glands, 157 

venereal, complication in injuries and dis- 
eases of the male sexual organs, 176 
Disks, intervertebral, inflammation of, 167 
Dislocations, acromio-clavicular articulation, 

as complication in sprains of the acromio- 
clavicular joint, 224 

as complications, sprains of back, 167 

ankle joint, 301 

dift'erential diagnosis m fractures involving 
ankle joint, 320 

compound, as complication in dislocation 
of shoulder joint, 228 

congenital, differential diagnosis in dislo- 
cations of hip, 289 

costal cartilages, 142^ 

differential diagnosis in sprains of back, 
167 

as complication in amputation of forearm, 

251 
as complication in fractures of the femur, 

310 
in differential diagnosis, fracture of femur, 

310 
as complication in sprains of foot and toes, 

304 

differential diagnosis in fractures ot the 
humerus, 244 

as complication in contusions of knee 
joint, 262 

complication in fractures of radius and 
ulna, 248 

of the ribs, complication in fractures and 
dislocations of the vertebrae, 170 

complication in sprains and dislocations 
of the pubic and sacro-iliac articula- 
tions, 283 

as complication in fractures of the tibia 
and fibula, 316 

as complication in sprains of the wrist 
joint, 235 

elbow joint, 231 

foot, 304 

fractures of thi femur, 310 

hands and fingers, 239 

hip joint, 287 

knee joint, 294 

partial or complete, complication in sprains 
of knee joint, 294 

patella, 296 

pubic articulation, 282 

ribs, 142 

sacro-iliac, 282 

sternum, complication in fractures and dis- 
locations of vertebrae, 170 

semi-lunar cartilages, 298 

shoulder joint, 226 

sterno-clavicular articulation, 136 

sternum, 140 

temporary, complication in sprains of el- 
bow joint, 230 

temporary, differential diagnosis in sprains 
of the wrist joint, 234 

temporo-maxillary articulation, 105 

toes, 304 

vertebrae, 168 

vertebral column, as a complication in 
sprains of the back, 167 

wrist joint, 235 



Displacements, lateral, of the patella, differ- 
ential diagnosis in fractures of patella, 
314 
Disseminated neuritis, 358 
Distention of abdomen, hysterical, differen- 
tial diagnosis in peritonitis, 516 
bladder, differential diagnosis in ascites, 
503 
Dogwood, poison, 562 

Dorsalis, tabes, 343 ^ 

Dorso-intercostal neuralgia, 352 
Dropsy of abdomen, 503 

peritoneal, 503 
Dupuytren's fracture, complication in dislo- 
cation of ankle, 302 
Dura mater, hematoma of, 349 
Dysentery, in diagnosis of catarrhal enteritis, 
435 
acute, 433 
amebic, 433 
bacillary, 433 
catarrhal, 433 

differential diagnosis, ptomaine poisoning, 
588 
Dyspnea, differential diagnosis in asthma, 392 

EAR, abscess of the, as complication, pharyn- 
gitis, 413 
abscess of the middle, 92 
acute abscess of the middle, complication, 

in acute nasal catarrh, 398 
abscess of the middle, as complication in 

acute tonsilitis, 423 
disease, middle, differential diagnosis in 

facial paralysis, 362 
injuries of the auricle, 90 
Early adjustment (accident), 599 
Eczema, 330 

differential diagnosis, abrasions of face, 71 
differential diagnosis in abrasions of 

scalp, 62 
differential diagnosis in ivy poisoning, 564 
Eczematous ulcer, 335 

Edema, complication in injuries of the larj^nx 
and trachea, 125 
differential diagnosis in croupous pneu- 
monia, 419 
lungs, complication in hay asthma, 393 
lungs, differential diagnosis in catarrhal 
pneumonia, 415 
Edematous laryngitis, differential diagnosis in 

acute catarrhal laryngitis, 408 
Effusion, pericarditis with, 411 
Elective indemnities in accident policies, 50 
Effusion, pericardial, differential diagnosis in 

dilatation of the heart, 376 
Elbow, 

abrasions, 206 
burns, 211 
contusions, 206 
dislocations, 231 
incisions, 208 
lacerations, 208 
punctured wounds, 209 
scalds, 211 
sprains of the, 229 
Embolism, complication in acute endocardi- 
tis, 374 
Emetic, tartar, 528 
Empyema, complication, punctured wounds 

of chest, 131 
Emphi'sema, 401 

as sequelae in asthma, 392 
as complication in abrasions and contu- 
sions of chest, 128 
as complication in punctured wounds of 

chest, 131 
of the lungs, as sequeire in catarrhal pneu- 
monia, 4:6 
as complication in abrasions and contu- 
sions of neck, 117 



INDEX 



633 



Emphysema, as complication in incisions and 

lacerations of neck, 120 
as complication in punctured wounds of 

neck, 121 
as sequelae in whooping cough, 427 
pulmonary, 401 
subcutaneous, complication in punctured 

wounds of chest, 132 
vesicular, 401 
Encephalitis, acute, 100 

suppurative, 100 
Endocarditis, acute, 373 

complication in acute articular rheumatism, 

S19 
chronic, 385 
exudative, 373 
as complication in croupous pneumonia, 

differential diagnosis in pericarditis, 382 
interstitial, 385 
sclerotic, 385 
simple, 373 . 

ulcerative, diiiferential diagnosis, typhoid 
fever, 496 
English cholera, 431 
Engorgement, pulmonary, 409 
Enlargement of the heart, 375 

glands of the groin, complication in gon- 
orrhea, 187 
liver, syphilitic, differential diagnosis in 

carcinoma of liver, 456 
liver, differential diagnosis in pleuritis, 411 
prostate gland, 194 
testes, syphilitic, differential diagnosis in 

cancer of the penis and testes, 179 
of the testes, syphilitic, differential diag- 
nosis in epididymitis and orchitis, 181 
Enteritis, acute, differential diagnosis in 
peritonitis, 516 
acute catarrhal, diagnosis in acute dysen- 
tery, 433 
catarrhal, 43s 
catarrhal, differential diagnosis in typhoid 

fever, 496 
differential diagnosis in intestinal obstruc- 
tion, 446 
Enteric fever, 493 
Entero-mesenteric fever, 493 
Enterorrhea, 436 
Ephemeral fever, 492 
Epidemic catarrh, 405 
cholera, 504 
fever, 405 
Epididymitis and orchitis, 180 

as complication in gonorrhea, 187 

as complication in incisions and lacerations 

of male sexual organs, 177 
and orchitis, cancer of penis or testes, 179 
' differential diagnosis, in varicocele, 199 
Epilepsy, 341 
idiopathic, 341 
sequel c in sun-stroke, 366 
Epistaxis, differential diagnosis in hemopty- 
sis, 404 
Erysipelas, 509 

as complication in punctured wounds of 

the back, 162 
differential diagnosis in eczema, 331 
as complication in abrasions of face, 72 
as complication in burns and scalds of 

face, 79 
as complication in incisions of face. 74 
as complication in punctured wounds of 

face, 76 
as complication in amputation of the foot, 

323 
as complication in abrasions and contusions 

of neck, 117 
as complication in abrasions of scalp. 62 
as complication i.i burns an 1 scalds of 

scalp. 60 
as complication in incisions of scalp. 65 



Erysipelas, as complication in punctured 
wounds of scalp, 67 

as complication in lacerations of scalp, 66 

as complicr tion in burns anrl scalds of 
shoulder and arm, 206 

as complication in puncturerl wounds of 
shoulder and arm, 204 

as complication in punctured wounds of 
skull, 98 
Erysip latous dermatitis, 509 
Erythromelalgia, 352 

Erythema, intertrit^o, differential diagnosis in 
abrasions of face, 7} , , 

simplex, differential diagnosis in abrasions 
of face, 71 
Esophagus, punctures of, complication in 

punctured wounds of chest, 132 
Essential asthma, 390 

salt of lemon, 572 
Estivo-autumnal fever, 4S2 
Examination before policy is issued, 4 

accident, 25 

blank (accident), 29 

of claimant, cross, 18 

demand for, 2 
health, 35 
liability, 41 

health, 32 

liability, 37 

microscopic, 3 _ 

medical in accident policies, 55 

permission to make (liability), 38 

place of (accident), 24 

place of (health), 31 

place of (liability), 39 

purpose of (accident), 23 

purpose of (health), 31 

purpose of (liability), 38 

time of, 2 

urinary, 3 

with attending physician (accident), 25 

with attending physician (health), 31 

without attending physician (accident), 24 

without attending physician (health), 31 
Examiner, good impression by, 19 

no prescribing by (accident), 27 

no prescribing by (liability), 45 

relations of (liability), 39 
Exhaustion, heat, 365 

nervous, 354 
Exanthematic typhus, 49S 
Experience, 1 1 
Explanations. 10 

Explanation of liability blank. 42-45 
Exposure to cold, differential diagnosis in 

facial paralysis. 362 
Externa, pachymeningitis, 340 
Extra capsular fractures. dilTerer^.tial diag- 
nosis, dislocation of hip joint. rS> 
Extract. Goulard's, poisoning. ^42 
Extravasation of blood and urine, complica- 
tion in incisions and lacerations of male 
sexual organs. 177 
Extremity, amputations of upper, _-4; 
Exudative endocarditis. 373 
Eye. loss of one. 48 
Eyes, loss of two, 48 
Eyelids. 

abrasions. So 

burns. _ S3 

contusions. So 

incisions. Si 

injuries. So 

lacerations. Si 

punctured wounds. Si 

scalds, v'^3 

FACI<:. ^ 

abrasions. 70 
burns. 77 
oontnsions. 7.: 
incisions. 73 
lacerations. 74 



634 



INDEX 



Face, punctured wounds, 75 

scalds, T7 

tumors of, in differential diagnosis in con- 
tusions of face, 73 
Facial paralysis, 361 
Fainting, differential diagnosis in apoplexy, 

339 
Falling sickness, 341 . 

Fallopian tubes, diseases _ of the, differential 

diagnosis in appendicitis, 429 
Famine fever, 487 
Febris recurrens, 487 
Febricula, 492 
Fees and bills, 21 

in court trials, additional, 4 
for surgical operations in accident poli- 
cies, 50 
Felon, 332 _ - . 

Fehling's solution, reduction of. ditterentiai 

diagnosis in diabetes mellitus, 506 
Femur, amputation of the, 311 

fractures of the, 308 
Fever, 

autumnal, 493 

bilious, 439-482 

bilious malignant, 500 

bilious remittent, 482 

bilious typhoid, 487 

break-bone, 479 

camp, 498 

catarrhal, 405 . . 

catarrhal enteritis, 435 

cerebral, 347 . . ^ , , 

cerebral, symptoms in, in acute cerebral 

leptomeningitis, 348 
cerebro-spinal, 477 
, chills and, 480 
congestive, 484 
contagious, 405-498 
continued, simple, 492 
dandy, 479 
ephemeral, 492 
epidemic, 405 
enteric, 493 
entero-mesenteric, 493 
estivo-autumnal, 482 
famine, 487 
gastric, 439-493 

hay, 393 , • o 

hectic, differential diagnosis, 481 . 
infectious, as sequelie, pharyngitis, 414 
intermittent malarial, 480 
irritative, 492 
jail, 498 
jungle, 482 
lung, 416 

malarial, intermittent, 4»o , . t^^^:* 

malarial, pernicious, sequels m intermit- 
tent malarial fever, 481 
malignant, intermittent, 484 
malignant, remittent, 484 
marsh, 482 
jMediterranean, 500 
nervous, 493 
neuralgic, 479 . 

pernicious malarial, 484 . 

pernicious 'malarial, as sequehe m int^i- 

mittent malarial fever, 481 
putrid, 498 
relapsing, 487 
remittent, 482 
lemittent, bilious, 482 
remittent, malignant 484 .. 

remittent, differential diagnosis m acute 
gastric catarrh, 440 ,. . . , ^ 

remittent, differential diagnosis m relaps- 

ins: fever, 488 . . ,, 

remittent, differential diagnosis in yellow 

fever, 500 
rheumatic, 5^7 
rose, 393 
sailors', 500 
scarlet, 489 



Fever, scarlet, differential diagnosis in acute 
tonsilitis, 423 
scarlet, differential diagnosis in dengue, 

479 . 
scarlet, differential diagnosis in diphtheria, 

400 
scarlet, differential diagnosis in measles, 

486 
ship, 498 

simple, continued, 492 
spirillum, 487 
spotted, 477-498 
swamp, 480 
thermic, 365 
typhoid, 493 

tj^phoid, as complication in appendicitis, 430 
typhoid, differential diagnosis in appendi- 
citis, 430 
typhoid, differential diagnosis in catarrhal 

enteritis, 435 
typhoid, differential diagnosis in cerebro- 
spinal fever, 477 
typhoid, differential diagnosis in acute gas- 
tric catarrh, 440 
differential diagnosis, pernicious malarial 

fever, 485 
typhoid, differential diagnosis - in remittent 

fever, 483 
typhoid, differential diagnosis in typhus 

fever, 498 
typho-malarial, 482 
typhus, 498 

abdominalis, 493 
typhus, differential diagnosis in cerebro- 
spinal fever, 477 
typhus, differential diagnosis in relapsing 

fever, 489 
typhus, differential diagnosis, smallpox, 524 
winter, 416 
yellow, 500 
yellow, differential diagnosis in pernicious 

malarial fever, 485 
yellow, differential diagnosis in relapsing 

fever, 488 
yellow, differential diagnosis in remittent 
fever, 483 
Fibrinous pneumonia, 416 
Fibroid heart, 379 
Fibrous myocarditis, 378 
Fibula, fractures of the, 315 
Fire, St. Anthony's, 509 
Fingers, 

abrasions, 213 
burns, 220 
contusions, 213 
dislocations, 239 
incisions, 215 
lacerations, 215 
punctured wounds, 217 
scalds, 220 
sprains, 2^7 
Fistula, complication in ischio-rectal abscess, 
193 
in ano, 184 

tuberculous, differential diagnosis in fis- 
tula in ano, 185 
Fits, 341 

Fixed alkalies, poisoning by, 582 
Flies, Spanish, 579 
Flux, alvin, 436 

bloody, 433 
Follicular conjunctivitis, dift'erential diag- 
nosis, conjunctivitis, 89 
tonsilitis, 422 

tonsilitis, differential diagnosis in diph- 
theria, 400 
Foot, 

abrasions, 2^6 
amputation of the, 323 
burns, 281 
contusions, 27^ 
dislocation, 304 



INDEX 



635 



Foot, incisions, 277 

lacerations, z^jy 

punctured wounds, 279 

scalds, 281 

sprains, 303 
Forearm, 

abrasions, 206 

amputation, 250 

burns, 211 

contusions, 206 

incisions, 208 

lacerations, 208 

punctured wounds, 209 

scalds, 211 
Forms, policy, knowledge of (accident), 599 

health, 606 
Fortis, aqua, 547 
Fothergill's disease, 352 
Fractures, 

acromion process, as complication, 225 

ankle, 319 

bones, complication in dislocation of el- 
bow joint, 232 

carpal bones, 251 

carpus, differential diagnosis in fractures 
of carpal bones, 252 

clavicle, 138 

Colics', 249 

Colics', differential diagnosis in dislocation 
of wrist joint, 236 

comminuted, complication in fracture of 
superior maxiliary, iii 

complete or partial, as complication in 
punctured wounds _ of leg, 273 

compound, as complication in fractures of 
carpal bones, 252 _ 

compound, as complication in fractures of 
the pslvis, 306 

compound, differential diagnosis in frac- 
tures of the superior maxillary, iii 

Dupuytren's, as complication, dislocation of 
ankle joint, 302 

■extra capsular, differential diagnosis, dislo- 
cation of hip, 288 

longitudinal, 316 

Pott's, complication in dislocation of ankle, 
302 

and dislocations of vertebral column, com- 
plication in sprains of the back, 167 

femur, 308 

libula, 315 

humerus, 243 

hyoid bone, complication in abrasions and 
contusions of neck, 117 

inferior maxillarj-, 112 

malar bones, 109 

meta-carpal bones, 254 

metatarsus, 321 

nasal bones, 107 

patella, 313 . ,. , . , , 

patella, as complication, dislocation ot knee 
joint, 29s 

pelvis, 306 

phalanges (fingers), 256 

phalanges (toes), 324 ,. , . , 

Pott's, as complication, dislocation ot 
ankle joint, 302 ,. , • r 1 

processes, complication in dislocation 01 el- 
bow joint, 232 

radius, 247 

ribs, 142 ,. • • i 

of ribs or vertebra;, complication in abra- 
sions and contusions of chest. 128 
of ribs, complication in fractures and dis- 
locations of the vertebrre, 170 
scapula. 241 
skull, 94 

sternum. 140 .... , 

sternum, as complication 111 alxasions ana 

contusions of the chest, 128 
of sternum, complication m traotures and 
dislocations of vertebra, 170 



Fracture, superior-maxillary, tii 

superior-maxillary, as complication in 
fracture of the malar bones, 1:0 

tarsus and metatarsus, 321 

tibia, 315 

ulna, 247 

vertebrae, 168 

as complication in sprains of the acromio- 
clavicular and shoulder joints, 224 

as complication in sprains of the ankle, 300 

differential diagnosis in sprains of the 
ankle, 299 

complication in burns and scalds of back, 
164 

differential diagnosis in dislocations of el- 
bow joint, 232 

as_ complication in sprains of the elbow 
joint, 230 

as complication in amputation of femur, 

312 

as complication in dislocations of bones of 

foot and toes, _ 305 
as complication in sprains of the foot and 

toes, 304 
as complication in dislocations between the 

joints of the hands and fingers. 240 
as complication in dislocations of the hip 

joint, 289 
as complication in punctured wounds of 

the hip and thigh, 265 
as complication in sprains of the hip joint, 

286 
as complication in sprains of knee joint, 294 
as complication in fractures of the nasal 

bones, 107 
as complication in dislocation of the pa- 
tella, 297 
as complication in sprains of pubic and 

sacro-iliac articulations, 283 
differential diagnosis in dislocation of 

shoulder joint, 226 
as complication in sprains of wrist joint, 

differential diagnosis in sprains of wrist 
joint, 234 
Fractured bones, complication in punctured 

wounds of elbow and forearm, 210 
Fraudulent claims, ability to detect (acci- 
dent), 603 
health, 609 

claims, dift'erential diagnosis in incisions 
and lacerations of leg, 271 
abrasions of scalp, 61 
Furuncle. Z-7_ 

in dift'erential diagnosis of carbuncle, 329 

GALL-BLADDER, wounds, 149 
Gall-stones, 453 

impacted, differential diagnosis in abscess 
of liver. 451 
Gangrene of the lung as complication in ab- 
"scoss of the lung. 3S0 

of the lung as complication in punctured 
wound of chest, ijj 
Gangrenous app.Mulicitis, complication. 430 
Gas. carbon di.>xid. 59.1 

carbon monoxid. 592 

carbonic acid. 59.) 

carbonic oxid, 502 

coal. 502 

illuminating-, 502 

water, 592 
Gastialgia. 437 . , 

ilifTcrontial diagnosis in gastric ulcer. 444 

ditTerontial dia>vMiosis in cholelithiasis. 45a 
Gastric car.cer. differential diagnosis in gas- 
tialgia. 43S 

catarrh, acute, 430 

fever, 439-493 

ulcer. 443 .. . . , . 

uleoi. ditTerontial diagnosis in gastralgia. 

43^^ 



636 



INDEX 



Gastric ulcer, chronic, 443 
Gastritis, acute, differential diagnosis in peri- 
tonitis, 516 
acute, simple, 439 
acute, toxic, 441 
chronic, differential diagnosis in gastric 

ulcer, 444 

sub-acute, 439 

Gastrodynia, 437 

Gastro-enteritis, acute toxic, differential diag- 
nosis in cholera, 506 
Gastro-intestinal catarrh, complication in 

measles, 487 
General diffuse myelitis, 350 

health or disability policy, 56 
Gin-drinkers' liver, 457 
Girdle, a, 334 

Gland, enlargement of the, of the groin, com- 
plication in gonorrhea, 187 
enlargement of prostate, T94 
suppuration of the, of the groin, 156 
suppuration of the parotid, complication, 

506 
swelling of the parotid, complication, 499 
thyroid, differential diagnosis in abrasions 
and contusions of neck, 116 
Gljxosuria, 507 

simple, differential diagnosis, 507 
Gonagra, 511 
Gonorrhea, 186 

as complication in cystitis, 470 
Gonorrheal arthritis, as complication in gon- 
orrhea, 186 
arthritis, differential diagnosis in sprains 

of knee joint, 292 
conjunctivitis, differential diagnosis, con- 
junctivitis, 88 
ophthalmia, complication Jn gonorrhea, 187 
rheumatism, differential diagnosis in acute 

articular rheumatism, 518 
rheumatism, differential diagnosis in dislo- 
cations of knee joint, 295 
Good impression by examiner, 19 
Goulard's extract poisoning, 542 
Gout, SI I 

as complication in angina pectoris, 373 
differential diagnosis in acute articular 
rheumatism, 519 
Gouty kidney, 467 
Graduation, 10 
Grafting, skin, 164 
Grand mal, 341 
Granular conjunctivitis, 89 

kidney, red, 467 
Gravel, 473 

green, Scheele's, 531 
Grippe, La, 405 , , , , r ^t. 

Groin, enlargement of the glands of the, 
complication in gonorrhea, 187 

HANDS, 

abrasions, 213 

burns, 220 

contusions, 213 

dislocations, 239 

incisions, 215 

lacerations, 215 

punctured wounds, 217 

scalds, 220 

sprains, 237 
Hardening of the liver, 457 
Hartshorn, 578 
Hay asthma, 393 

differential diagnosis m asthma, 392 

fever, 393 . , . ^ , 

Headache, persistent, sequelse m sun-stroke, 
366 

sick, bilious or blind, 346 
Head, cold in the, 397 
Health claims, adjusting, 605 

manner of adjusting, 608 

examinations, 30 



Health claims, examination blank, 35 
policies, 56 

policy, the general, 56 
policy, special, 56-59 
policy, unlimited, 57 
Heart, abscess of the, 379 

as complication in abrasions and contU' 

sions of the chest, 128 
dilatation of the, 375 
dilatation of the, differential diagnosis ii> 

pericarditis, 382 
enlargement of the, 375 
fibroid, 379 
hypertrophy of the, differential diagnosis 

in pericarditis, 382 
lungs and joints as complication in scarlet 

fever, 491 
neuralgia of the, 372 

organic disease of the, complication, 468 
valvular diseases of the, 385 
Heat exhaustion, 365 

stroke, 365 
Hectic fever, differential diagnosis in in- 
termittent malarial fever, 481 
Height, weight and age, 16 
Hematemesis, differential diagnosis in hemop- 
tysis, j^04 
Hematocele, 190 

as complication in hydrocele and hemato- 
cele, 191 
differential diagnosis in hernia, 155 
Hematoma of the dura mater, 349 

auris, complication in injuries of auricle, 91 
Hemicrania, 346 
Hemoptysis, 403 
Hemorrhage, 403 
bronchial, 403 
broncho-pulmonary, 403 
cerebral, 339 

differential diagnosis In hemoptysis, 404 
meningeal, sequels in whooping cougla, 427 
as complication in gastric ulcer, 444 
as complication in typhoid fever, 496 
involving spinal cord, differential diagnosis 

in acute myelitis, 351 
secondary, complication in fracture of the 
superior maxillary, 11 1 
Hemorrhagic pachymeningitis, 349 

pancreatitis, acute, differential diagnosis, 

446 
smallpox, 524 
ulcer, 335 
Hemorrhoids, 188 

Hemothorax, as complication in pneumo- 
thorax, 421 
as complication in punctured wounds of 

chest, 131 
as complication in abrasions and contusions- 
of chest, 128 
Henbane, 558 

Hepatic abscess, complication in acute dysen- 
tery, 434 
calculi, 453 
cancer, 456 
colic, 453 

differential diagnosis In intestinal ob- 
struction, 446 
Hepatitis, acute, 451 
catarrhal, 460 
interstitial, 457 
parenchj-matous, 451 
suppurative, 451 
Hepatic colic, 453 

differential diagnosis in intestinal obstruc- 
tion, 446 
Hernia, 151 

as complication in incisions and lacerations 

of the abdominal walls, 146 
of the omentum, 199 
strangulated, 445 
strangulated, as complication of hernia, 15S 



INDEX 



0:^7 



Herpes, zoster, 334 

zoster, differential diagnosis in eczema, 330 
differential diagnosis, erysipelas, 510 
differential diagnosis in burns and scalds 
of eyelids, 84 
Herpetic ulcers, differential diagnosis in cor- 
nea and sclera, 86 
Hip, 

abrasions, 259 
burns, 266 
contusions, 259 
dislocations, 287 
incisions, 262 
lacerations, 262 
punctured wounds, 264 
scalds, 266 
sprains, 284 
Hip gout, z^iZ 

Hip joint disease, differential diagnosis in 
dislocation of hip joint, 288 
differential diagnosis in appendicitis, 430 
differential diagnosis in sprains of hip 
joint, 284 
Hob-nailed liver, 457 
Hooping cough, 427 
Humerus, fractures of, 243 
Hydatid cysts,_ differential diagnosis in ab- 
scess of liver, 451 
Hydrocele and hematocele, 190 
Hydrocele, differential diagnosis in hydrocele 
and hematocele, 191 
differential diagnosis in hernia, 155 
Hydrochloric acid, 538 
Hj'drccyanic acid, 539 
Hydrogen, sulphide 594 

sulphuretted, 594 
Hydro-peritoneum, 503 
Hydrophobia, 513 

as complication in punctured wounds of 

hip and thigh, 265 
as complication in punctured wounds of 

the leg, 274 
differential diagnosis in belladonna, stra- 
monium and hyoscyamus, 558 
differential diagnosis in cocaine, 560 
differential diagnosis in tetanus, 368 
Hydropneumothorax, 420 

Hydrothorax, as complication in pneumotho- 
rax, 421 
differential diagnosis in pleuritis, 411 
Hyoid bone, fracture of, complication in 

abrasions and contusions of neck, 117 
Hyoscyamus poisoning, 558 
Hyperemia, spinal, 346 

of the liver, 459 
Hypertrophy, 375 

differential diagnosis in dilatation of the 

heart, ZT^ 
of the heart, differential diagnosis in per- 
icarditis, 382 
Hypostatic congestion, 409 

Hysteria, differential diagnosis in hydropho- 
bia, 513 
differential diagnosis in_ neurasthenia, 355 
traumatic, differential diagnosis in concus- 
sion of spinal cord, 173 
Hysterical joint, differential diagnosis in con- 
tusions of knee joint, 261 
distention of abdomen, differential diag- 
nosis in peritonitis, 516 
paraplegia, differential diagnosis in acute 
myelitis, 351 

ICTERODE, typhus, 500 

Icterus, 460 

Identification in accident policies, 53 

Idiopathic epilepsy, 341 

muscular atrophy, differential diagnosis in 
progressive muscular atrophy. 345 
Ileocolitis, differential diagnosis in catarrhal 

enteritis, 435 
Ileus, 445 



Iliac, abscess, 429 

Illuminating gas, 592 

Impacted gall-stones, differential diagnosis in 

abscess of liver, 451 
Impaired mental activity, sequelae in sun- 
stroke, z^^ 
Impartial reports, 19 
Impression by examiner, gooa, ly 
Incipient phthisis, 424 
Incised or lacerated wounds, 161 
Incisions of, 

abdominal walls, 146 

arm, 202 

back, 160 

chest, 129 

differential diagnosis in injuries of larynx 
and trachea, 125 

elbow, 208 

eyelids, 81 

face, TZ 

fingers, 215 

foot, 2T] 

forearm, 208 
hands, 215 
hip, 262 
leg, 270 

male sexual organs, 176 
neck, 119 
scalp, 65 
shoulder, 202 
thigh, 2()2 
toes, 2'j7 
wrist, 215 
Increasing acquaintance, 5 
Indemnity, elective, in accident policies, 50 
for partial disability in accident policies, 49 
partial for total disability in health poli- 
cies, 59 
quarantine in health policies, 59 
special death, in accident policies. 51 
for total disability in accident policies, 4S 
Indemnities, surgical, in health policies, 59 

elective, in accident policies. 50 
Indigestion, acute, 439 
Infection, as complication in incisions and 

lacerations of arm and shoulder, 202 
complication in burns and scalds of back. 

164 
as complication in punctured wounds of 

back, 162 
bladder, tuberculous, as complication in 

cystitis, 470 
as complication in burns and scalds of 

chest and abdomen, 135 
as complication in punctured wounds of 

elbow and forearm, 210 
complication in abrasions of face. 72 
complication in burns and scalds of face, 

79 
as complication in incisions of face. 74 
as complication in incisions and lacerations 

of foot and toes, 278 
as complication in punctured wounds of 

foot and toes, 2S0 
as complication in abrasions and contu- 
sions of leg. 269 
as complication in fracture of inferior 

maxillary, 113 
as complication in punctured wounds of 

neck. 121 
as complication, abrasions of scalp. 6j 
complication in burns and scalds of scalp. 

60 
as complication in lacerations of scalp. (\f^ 
as complication in punctured wounds of 

scalp. 67 
as comi^lioation in burns and scalds of 

shoulder and arm. 206 
as complication in punctured wounds of 

shoulder and arm. 204 
complication in fractures of skull. 06 



638 



INDEX 



Infection, complication in punctured wounds 
of skull, 98 _ 

as" complication in abrasions and contusions 

of wrist, hands and fingers, 214 
as complication in punctured wounds of 

wrist, hands and fingers, 219 
as complication in incisions and lacerations 
of wrist, hands and fingers, 216 
Infectious fevers, as sequelae, pharyngitis, 414 
Inferior maxillary, fracture of, 112 
Inflammation of the bladder, 469 
bowels, 435 
kidneys, acute, complication in acute toxic 

gastritis, 441 
peritoneum, 515 
pleura, 410 
vein, 383 
Inflammatory rheumatism, 517 
Influence with agent, 615 

with medical director, 614 
Influenza, 405 

differential diagnosis in acute bronchitis, 
396 
Information, bureau of, 624 
Inguinal glands, suppuration of, 156 
Injuries of auricle, 90 

blood vessels and nerves, as complication 

in dislocation of elbow joint, 2^2 
to the blood vessels and nerves as complica- 
tion in dislocation of shoulder joint, 228 
eyelids, 8cr 
joint, as complication in punctured wounds 

of leg, 273 
larynx and trachea, 124 
male urethra, 195 
nerves, complication in fractures to the 

radius and ulna, 248 
pancreas, as complication, punctured 

wounds of abdomen, 149 
stomach, 149 
skull, 94 

uterus and vagina, complication in frac- 
tures of pelvis, 306 
Insanity, as complication in sun-stroke, 366 
as complication in concussion of brain. 104 
Insipidus, diabetes, differential diagnosis in 

diabetes mellitus, 507 
Insolation, 365 
Inspection, 16 

Insurance, beneficiary in accident policies, 54 
journals, papers for, 614 
physicians welcome (accident), 4 
Intercostal neuralgia, differential diagnosis in 
gastralgia, 438 
differential diagnosis in pleurisy, 411 
Intermittent fever, 480 

differential diagnosis in remittent fever, 

483 
malignant. 484 
malarial fever, 480 
Interna, pachymeningitis, differential diag- 
nosis in multiple neuritis, 359 
Interstitial endocarditis, 385 
hepatitis, 457 
myocarditis, chronic, 379 
nephritis, 467 
nephritis, chronic, 467 
Intertrigo erythema, differential diagnosis in 

abrasions of face, 71 
Intercostal neuralgia, 334 
Intervertebral disks, inflammation, 167 
Intestinal catarrh, 43s 

colic, differential diagnosis in cholelithia- 
sis, 455 
gastro, complication m measles, 487 
obstruction, 44=; 

obstruction, differential diagnosis in perito- 
nitis, 5t6 
occlusion, 445 
perforations, 149 
stricture, 445 
Intestines, rupture of the, 145 



Intoxication, uremic, 475 
Invagination, 445 
Iodine poisoning, 586 

Irritability, nervous, complication in occupa- 
tion neurosis, 360 
Irritation, spinal, 354 
Irritative fever, 492 
Ischio-rectal abscess, 192 
Ivy poisoning, 562 

JACK, yellow, 500 
Jail fever, 498 
Jamestown weed, 558 
Jaundice, catarrhal, 460 

catarrhal, differential diagnosis in conges- 
tion of the liver, 459 

differential diagnosis in catarrhal jaundice, 
460 

obstructive, differential diagnosis, conges- 
tion liver, 459" 
Jimson weed, 558 
Joint, 

ankle, dislocation of, 301 
sprains of, 299 
fractures involving, 319 
punctured wovinds, 272 

elbow, dislocation of, 231 

elbow, sprains of, 229 

hip disease, differential diagnosis in ap- 
pendicitis, 430 

hip disease, differential diagnosis in dislo- 
cation of hip, 288 

hip. dislocations of, 287 
sprains of, 284 

hysterical, differential diagnosis, contusions 
of knee joint, 261 

injuries, as complication in punctured 
wounds of leg, 273 

knee, contusions of, 260 
dislocations of, 294 
punctured wounds, 272 
sprains of, 291 

shoulder, dislocation of, 226 
sprains, 223 

tuberculosis of the sacro-iliac, differentia! 
diagnosis in sprains and dislocations of 
the pubic and sacro-iliac articulations, 
282 

wrist, dislocation of, 235 

wrist, sprains of, 233 
Journals, papers for insurance, 614 
Jungle fever, 482 

KAKKE, 358 

Keratitis, simple, differential diagnosis in 
cornea and sclera, 86 

phlyctenular, 86 
Kermes, mineral, 528 

Kidneys, acute inflammation of, complication 
in acute toxic gastritis, 441 

congestion of, 463 

congestion of, complication in acute ton- 
silitis, 423 

contracted, 467 

gouty, 467 

large white, 465 

movable, differential diagnosis, 474 

penetrating wounds of, 150 

red granular, 467 

sclerosis of, 467. 
Knee joint, contusions of, 260 

dislocations of, 294 

punctured wounds of, 272 

sprains of. 291 
Knowledge of policy forms (accident), 599 

health, 606 
Known, becoming well, 613 

LACERATIONS, 

abdominal walls, 146 
arm, 202 



INDEX 



6313 



Lacerations, back, i6o 

chest, 129 

elbow, 208 

eyelids, 81 

face, 74 

fingers, 215 

foot, 2-/7 

forearm, 208 

hands, 215 

hip, ^()2 

leg, 270 

male sexual organs, 176 

neck, 119 

scalp, 66 

shoulder, 202 

thigh, 2612. 

toes, 277 

wrist, 215 
La Grippe, 405 
Large white kidney, 463 
Laryngitis, 407 

acute catarrhal, 407 

catarrhal, 407 

croupous, differential diagnosis in acute 
catarrhal laryngitis, 408 

diphtheritic, as complication in acute ca- 
tarrhal laryngitis, 408 

edematous, differential diagnosis in acute 
catarrhal laryngitis, 408 

spasmodic, differential diagnosis in acute 
catarrhal laryngitis, 408 

and pharyngitis, complication in acute 
nasal catarrh, 398 

as complication in acute nasal catarrh, 398 

as complication in pharyngitis, 414 
Larynx, injuries of, 124 

abscess of, 125 

complication in injuries to larynx and 
trachea, 125 

edema of, 125 

ulcers of, as complication in acute catarrhal 
laryngitis, 408 
Lateral displacements of patella, differential 
diagnosis, fractures of patella, 314 

sinus, thrombosis of, differential diagnosis, 
abscess of brain, loi 

sclerosis, amyotropic, 344 
Lead, 542 

acetate, poisoning by, 542 

carbonate, 542 

Goulard's, 542 

poisoning, chronic, differential diagnosis in 
occupation neurosis, 360 

subacetate, 542 

sugar of, 542 

white, 542 
Leg, 

abrasions, 267 

amputation, 317 

burns, 275 

contusions, 267 

incisions, 270 

lacerations, 270 

punctured wounds, 2^2 

scalds, 27s 
Lemon, essential salt of, 572 
Leptomeningitis, acute cerebral. 347 

spinalis, 364 
Leucemia, 377 
Leucocythemia. 377 , . 

differential diagnosis in anemia, 371 
Leukemia, z^^ 
Leukocythemia, ZT7 
Liability claims, adjusting. 610 

examinations, 37 

examination blank. 41 

examination blank, explanation of, 4--45 
Lithiasis, nephro, 473 
Liver, abscess o£ the, 451 

abscess of the, differential diagnosis in 
carcinoma of the liver, 456 



Liver, abscess of the, complication in proc- 
titis, 448 

acute yellow atrophy, differential diagnosis 
in phosphorus, 551 

acute yellow atrophy, differential diagnosis 
in yellow fever, 501 

cancer of the, 456 

cancer of the, differential diagnosis in ab- 
scess of the liver, 451 

cancer of the, differential as complication, 
456 

carcinoma of the, 456 

cirrhosis of the, 457 

cirrhosis of the, differential diagnosis in 
carcinoma of the liver, 456 

congestion of the, 459 

enlargement of, differential diagnosis in 
ple'uritis, 411 

gin-drinkers', 457 

hardening of the, 457 

hob-nailed, 457 

hyperemia of the, 459 

lungs, heart, _ kidneys, diseases of, as com- 
plications in ascites, 504 

sclerosis of the, 457 

syphilitic enlargement of the, differential 
diagnosis, 456 

torpid, 459 

wounds of the, 149 
Limbs, loss of one in accident policies, 48 

loss of two, in accident policies, 48 
Lobar pneumonia, 416 
Lobular pneumonia, 414 

Localized peritonitis, as complication in 
cholelithiasis, 455 

peritonitis, as complication in proctitis, 449 
Lock-jaw, 1^7 
Locomotor ataxia, 343 

differential diagnosis in multiple neuritis, 
.359 

differential diagnosis in neuralgia, 353 
Loss of one limb or one eye, in accident 
policies, 48 

of two limbs or two eyes, in accident poli- 
cies, 48 _ 
Lumbago, differential diagnosis in muscular 

rheumatism, 521 
Lumbago, 520 

differential diagnosis, sprains of back. 166 
Lumbo-abdominal neuralgia, 352 
Ltimbodynia, 520 
Lung, abscess of the, 389 

acute tuberculosis of, complication in acute 
bronchitis, 396 

as complication, punctured wounds, chest, 
132 

circumscribed suppuration of, 3S9 

collapse, complication in abrasions and con- 
tusions of chest, 12S 

congestion of, 409 

diseases of, as complication in emphysema. 
402 

edema, as complication in hay asthma, 393 

edema of. differential diagnosis in catarrhal 
pneumonia. 415 

emphysema of. as sequels in catarrhal 
pneumonia. 416 

fever, 416 

gangrene of, complication in abscess of 
lung. 3S9 

gangrene of. complication in punctured 
wounds of lung. \Z- 

rupture and collapse of. complication in 
abrasions and contusions of chest. TiS 

tuberculosis of. 4-4 

tuberculosis of, as complication in hemop- 
tysis. 404 

tuberculosis of. as complication in plcun- 
tis. 411 

as sequel.-e in typhoid fever, 406 

sequcl.T. in whooping cough. 4J7 
r-yo, concentrated, poisoning by. sSa 



640 



INDEX 



MAL, grand, 341 
Malar^ bones, fracture of, 109 
Malarial, cachexia, sequelae in remittent 
fever, 483 
cachexia, chronic, complication in perni- 
cious malarial fever, 485 
fever, intermittent, 480 
fever, pernicious, 484 

sequel?e, intermittent malarial fever, 481 
Male sexual organs and surrounding parts, 
abrasions and contusions of, 175 
incisions, 176 
lacerations, 176 
Male urethra, injury to, 195 
Malignant cholera, 504 
fever, bilious, 500 
intermittent fever, 484 
remittent fever, 484 
smallpox, 524 
ulcerous sore-throat, 399 
Malingerers, differential diagnosis, in con- 
cussion of spinal cord, 173 
Manner of adjustment (accident), 600 
of adjustment (health), 608 
of payment (accident), 602 
of pa3-ment (health), 608 
Marginalis blepharitis, differential diagnosis 

in burns and scalds of eyelids, 84 
Marsh fever, 482 

Mastoid disease, _ differential diagnosis in ab- 
scess of brain, loi 
Mater, dura, hematoma of, 349 
Maxillary, inferior, fracture of. 112 

superior, fracture of, complication in frac- 
ture of malar bones, no 
fracture of, in 
Meadow, saffron, 561 
Measles, 486 

differential diagnosis in acute nasal ca- 
tarrh, 398 
differential diagnosis in dengue, 479 
differential diagnosis in scarlet fever, 490 
differential diagnosis in smallpox, 524 
differential diagnosis in typhus fever, 499 
Media, otitis, as a complication in scarlet 

fever, 491 
Medical attention, in accident policies, 54 
director, influence with, 614 
director, writing, 615 
examination, in accident policies. 55 
subjects, papers on, 614 
terms, 27 
Mediterranean fever, 500 
Megrim, 346 
Meningeal hemorrhages, sequelde in whooping 

cough, 427 
Melituria, 507 
Mellitus diabetes, 507 
Membranous, angina, 399 

croup, 399 
Meningitis, acute, 347 

acute,_ differential diagnosis, abscess of 

brain, loi 
acute spinal, differential diagnosis in acute 

myelitis, 351 
cerebro-spinal, epidemic, 477 
cerebro-spinal, as complication in spinal 

meningitis, 365 
cerebro-spinal, differential diagnosis in ty- 
phus fever, 499 
differential diagnosis, pernicious malarial 

fever, 485 
differential diagnosis in typhoid fever, 496 
spinal, 364 

spinal, dift'erential diagnosis in acute mye- 
litis, 351 
tuberculous, differential diagnosis in acute 

cerebral leptomeningitis, 348 
tuberculous, differential diagnosis in cere- 
bro-spinal fever, 478 
Mental activity, sequelae in sun-stroke, 366 
Mercury, 544 



^leta-carpal bones, fracture of, 254 
Metatarsus, fracture of, 321 
Method, 12 
diethyl alcohol, 576 
Microscopic examinations, 3 
Aliddle ear, abscess of, 92 

acute abscess of, complication in acute 

nasal catarrh, 39S 
abscess of, as complication in acute ton 

silitis, 423 
disease, differential diagnosis in facial 
paralysis, 362 
Migraine, 346 
Mild conjunctivitis, complication in acute 

nasal catarrh, 398 
Miliary _ tuberculosis, acute, differential diag- 
nosis in pulmonary tuberculosis, 425 
differential diagnosis in acute bronchitis 

.395 . 
differential diagnosis in typhoid fever, 494 
Mineral, Kermes, 528 

poisons, 527 
iModified smallpox, 524 
Monkshood, 556 

Monoxid, carbon, poisoning. 592 
Morbilli, 486 
Morbus, cholera, 431 

cholera, differential diagnosis in cholera 
506 
Morphine poisoning, 569 

Movable kidney, differential diagnosis, 474 
Multiple neuritis, 358 

neuritis, differential diagnosis in locomotor 
ataxia, 344 
Mumps, 514 

dift'erential diagnosis in abrasions and con- 
tusions of the neck, 116 
Muriatic acid, 538 

Muscle, abdominal, rheumatism of, dift'eren- 
tial diagnosis, peritonitis, 516 
deltoid, paralysis of, dift'erential diagnosis, 

Muscular atrophy, chronic spinal, 344 

atrophy, idiopathic, differential diagnosis 

in progressive muscular atrophy, 345 
atrophy, progressive, 344 
atrophy, progressive, differential diagnosis 

in muscular rheumatism, 521 
rheumatism, 520 

rheumatism, differential diagnosis in abra- 
sions and contusions of neck, 159 
Mushroom poisoning, 565 

Mutilation, self, dift'erential diagnosis in am- 
putation of toes, 326 
Mutual need, 623 

Mj'^algia, differential diagnosis in neuritis, 357 
Myelitis, acute, 350 

chronic, differential diagnosis in locomotor 

ataxia,_ 344 
differential diagnosis in spinal meningitis, 

364 
general dift'use, 350 
transverse, 350 
iNIyocarditis, acute, 379 
chronic, 379 
chronic interstitial, 379 
fibrous, 379 

as complication in acute articular rheuma- 
tism, 519 

NAPELLUS, aconitum, 556 
Nasal bones, fracture of, 107 

catarrh, acute, 397 
Neck, 

abrasions, 115 

burns, 122 

contusions, 115 

incisions, 119 

lacerations, 119 

punctured wounds, 121 

scalds, 122 , 



INDEX 



641 



Necrosis, complication, burns and scalds of 
back, 164 

as complication in felon, 333 

as complication in contusions of scalp, 64 
Need, mutual, 623 
Neoplasms, benign, differential diagnosis in 

cancer of penis or testes, [79 
Nephritis, 

acute, 463 

acute croupous, 463 

acute, as complication in cholera, 506 

acute desquamative, 4.63 

acute parenchymatous, 463 

acute tubular, 463 

chronic, 465 

chronic catarrhal, 465 

chronic croupous, 465 

chronic interstitial, 467 

chronic parenchymatous, 465 

chronic parenchymatous, differential diag- 
nosis in chronic interstitial nephritis, 467 

chron.ic tubular, 465 

diffuse, 467 

interstitial, 467 

pyelo, 471 

as complication in scarlet fever, 491 

as a sequelae of typhoid fever, 497 

suppurative, 471 
Nephro-lithiasis, 473 
Nerve, sciatic, neuralgia of, 363 
Nerves, injury to the, as complication in dis- 
location of elbow joint, 232 

injuries to the, as complication in disloca- 
tion of the shoulder joint, 22S 
Nervous asthma, 390 

exhaustion, 354 

fever, 493 

irritability, complication in occupation neu- 
rosis, 360 

prostration, 354 
Neuralgia, 352 

differential diagnosis in neuritis, 357 

intercostal, 334 

differential diagnosis in pleuritis, 41 1 

intercostal, differential diagnosis in gas- 
tralgia, 438 

heart, 372 

sciatic nerve, 363 

stomach, 437 
Neuralgic fever, 479 
Neurasthenia, 354 

differential diagnosis in intermittent ma- 
larial fever, 481 
Neuritis, 356 

complication in burns and scalds of back, 
164 

degenerative, 358 

disseminated, 358 

differential diagnosis in locomotor ataxia, 
344 

multiple, 358 

peripheral, 358 

simple, 3^6 

simple, differential diagnosis in neuralgia, 
352 
Neurosis, occupation, 359 
Night-shade, deadly, 558 
Nitric acid, 547 

differential diagnosis in hydrochloric acid, 
538 
Nitrobenzol, differential diagnosis in hydro- 
cyanic acid, 541 
No prescribing by examiner (accident). 27 

liability, 33 

health, 45 
Non-suppurating ulcers. differential diag- 
nosis in cornea and sclera. 86 
Nostras, cholera. 431 
Notice of accident, 53 
Nux vomica, 567 

OAK. poison. 56J 

41 



Obstruction, intestinal, 445 
bowels, 445 

intestinal, differential diagnosis in perito- 
nitis, 516 
Obstructive jaundice, differential diagnosis in 

congestion of liver, 459 
Occlusion, intestinal, 445 
Occupation, change of, in accident policies, 52 

neurosis, 359 
Oil of vitriol, 552 
Omentum, hernia of, 199 

Opening in diaphragm, complication in punc- 
tured wounds of chest, 132 
Operations, surgical, fees for, in accident 

policies, 50 
Ophthalmia, gonorrheal, 187 
Opium, 569 

chronic poisoning, 570 

differential diagnosis in apoplexy, 340 

poisoning, differential diagnosis in chloral, 

58s 
poisoning, differential diagnosis in cocaine, 
560 
Orchitis and epididymitis, 180 
and epididymitis, as complication in gouor 

rhea, 187 _ 
as complication in parotiditis, 514 
and epididymitis, differential diagnosis in 
cancer of penis and testes, 179 
Organic disease of the heart, complication 

468 
Organs, male sexual and surrounding parts 
abrasions and contusions of, 175 
incisions and lacerations of, 176 
Osteomyelitis, septic, as complication in con 

tusions of scalp, 64 
Otitis media, complication in scarlet fever 

491 
Ovaries, diseases of, differential diagnosis in 

appendicitis, 429 
Ovarian tumors, differential diagnosis in as 

cites, 503 
Oxalate, acid potassium. 572 
Oxalic acid, 571 
Oxid, carbonic, gas poisoning, 592 

PACHYMENINGITIS, externa, 349 
hemorrhagic, 349 

interna, differential diagnosis in multiple 
neuritis, 359 
Palmar abscess, 221 

as complication in abrasions and contu- 
sions of wrist, hands and fingers, 214 
Palsy, Bell's, 361 

wasting, 344 
Pancreas, injury as complication, punctured 

wounds of abdomen. 149 
Pancreatitis, acute hemorrhagic, differential 

diagnosis in intestinal obstruction. 446 
Papers for insurance journals on medical 

subjects. 614 
Paralysis, alcoholic, 35S 

of the deltoid muscle, dift'erential diag- 
nosis, 227 
facial. 361 

differential diagnosis in facial paralysis. 361 
post-diphtheritic. 401 
Paraplegia, hysterical, dift'erential diagnosis 

in acute myelitis, 351 
Parenchymatous hepatitis. 451 
nepliritis. acute. 463 
nephritis, chronic. 4(^5 

nephritis, chronic. difVerential diagnosis in 
chronic interstitial nephritis. 467 
Paris green, poisoning. 531 
Paronychia, 3-32 

Parotid gland, suppuration of. complication 
in cholera. 506 
swellinv; of. complication in typhus fever, 
490 
Parotiditis. 514 
Parotitis. 514 



642 



INDEX 



Parotitis, as complication' in epididymitis and 
orchitis, 182 
differential diagnosis in contusions of face, 

differential diagnosis in abrasions and con- 
tusions of neck, 116 
suppurating, complication in abrasions and 
contusions of neck, 117 
Partial ^ disability, indemnity for (accident 
policies), 49 
or complete dislocations, complication in 

sprains of knee joint, 294 
or complete fractures, as complication in 

punctured wounds of leg, 273 
indemnity for total disability (health poli- 
cies), 59 
Patella, dislocation of, 296 
fractures of, 313 
fractures of, as complication in dislocation 

of knee, 295 
lateral displacements, differential diagnosis 
in fractures of patella. 314 
Payments, advanced, in accident policies, 52 
manner of (accident), 602 
manner of (health), 608 
Pectoris, angina, 372 

differential diagnosis in gastralgia, 438 
Pelvis, fractures of, 306 

compound fractures of. complication, 306 
Pemphigus, differential diagnosis in burns 
and scalds of face, 78 
differential diagnosis in burns and scalds 

of elbow and forearm, 212 
differential diagnosis in burns and scalds 

of neck, 122 
differential diagnosis in burns and scalds 
of scalp, 69 
Penetrating wounds of the kidneys, 150 
Penis, cancer of, 178 
Peptic ulcer, 443 
Perforating ulcer, 443 
wounds of SKull, 97 
Perforation, as complication in typhoid 
fever, 496 
intestinal, 149 

stomach, complication in gastric ulcer, 444 
Pericaecal abscess, 429 
Pericardial effusion, differential diagnosis in 

acute endocarditis, 376 
Pericarditis, 381 
adhesive, 381 
chronic, 381 
differential diagnosis in acute endocarditis, 

374 . . 

as complication in- punctured wounds of 

chest, 132 
as complication in chronic interstitial ne- 
phritis, 468 
as complication in acute parenchymatous 

nephritis, 464 
with effusion, differential diagnosis in pleu- 

ritis, 411 _ 

as complication in acute articular rheuma- 
tism. 519 
Pericardium, complication in abrasions and 

contusions of chest, _ 128 
Perineal abscess, complication in incisions 
and lacerations of male sexual organs, 

177 
Perinephritic, abscess, differential diagnosis, 

471 

Perineum, abscess of. 196 

Periostitis, complication in abrasions and 
contusions of leg. 269 
acute, differential diagnosis in acute articu- 
lar rheumatism, 319 

Peripheral neuritis, 358 

Periproctitis, complication in proctitis, 448 

Peritoneal dropsy, 503 _ 

Peritoneum, inflammation of, 515 
hydro, 503 

Peritonitis, 513 



Peritonitis, acute tuberculous, differential 
diagnosis in appendicitis, 430 
as complication in acute dysentery, 433 
as complication in intestinal obstruction, 

447 .. . 
as complication in abscess of the liver, 452 
as complication in acute parenchymatous 

nephritis. 464 
chronic, differential diagnosis in ascites, 

5°3. . . . ■ 

chronic, differential diagnosis, cirrhosis of 

liver, 458 
differential diagnosis, in catarrhal enteritis, 

435 
differential diagnosis in intestinal obstruc- 
tion, 446 
diffuse, complication in appendicitis, 430 
localized, as complication in cholelithiasis,, 

455 
localized, as complication in proctitis, 449 
septic, as compl'cation in fractures of pel- 
vis, 306 
Perityphilitic abscess, 429 
Perityphilitis, 429 

Permanent disability (health policy), 57 
Perm'ssion to maVe examination (liability), 

38 
Pernicious malarial fever, 484 

sequels in intermittent malarial fever, 481 
Personal acquaintance, 620 

appearance, 9 
Pertussis, 427 
Petechial typhus, 498 
Phalanges, 

fractures of (fingers), 236 
fractures of (toes), 324 
Pharyngitis, 413 

acute catarrhal, 413 

differential aiagnosis in diphtheria, 400 

and laryngitis, complication in acute nasal 

catarrh, 398 
phlegmonous. 422 

rheumatic, differential diagnosis in pharyn- 
gitis, _ 413 
Phenacetin poisoning, 574 
Phenic acid poisoning, 534 
Phenol _ poisoning, 534 
Phenylic alcohol poisoning, 334 
Phlebitis, 383 

Phlegmonous pharyngitis, 422 
Phlyctenular conjunctivitis, 89 

keratitis, dift'erential diagnosis in cornea, 
and sclera. 86 
Phosphorus poisoning, 330 
Phthisis, 424 

Physician, examination with attending (acci- 
dent), 25 
accident insurance welcome, 4 
examination with attending (health), 31 
examination without attending (accident), 

24 
examination without attending (health), 31 
no criticism of attending (accident), 28 
no criticism of attending (health), 34 
time. 5 
Piano-players' cramp, 339 
Piles, bleeding, 188 
Place of examination (accident), 24 
of examination (health), 31 
of examination (liability), 39 
Players', piano, cramp, 359 

violin, cramp, 359 
Plethora spinalis, 346 
Pleura, inflammation of, 410 
Pleural cavity, air in, 420 
Pleurisy, 410 

as complication in abscess of liver, 452 
as complication in acute bronchitis, 396 
as complication in abrasions and contu- 
sions of chest, 128 
as complication in cholera, 506 



INDEX 



643 



Pleurisy, as complication in amputation of 
the femur, 310 

as complication in chronic interstitial ne- 
phritis, 468 

as complication in acute parenchymatous 
nephritis, 464 

as complication in croupous pneumonia, 419 

differential diagnosis in croupous pneu- 
monia, 419 

as complication in acute articular rheuma- 
tism, 519 
Pleuritis, 410 
Pleurodynia, 520 

differential diagnosis in muscular rheuma- 
tism, 521 

differential diagnosis in pleurisy, 411 
Pleuro-pneumonia, 416 
Pneumonia, 416 

aspiration, as complication in punctured 
wounds of neck, 121 

broncho, as complication in measles, 487 

catarrhal, 414 

catarrhal, _ differential diagnosis in acute 
bronchitis, 395 

croupous, 416 

croupous, as complication in pleuritis, 411 

croupous, differential diagnosis in ca- 
tarrhal pneumonia, 415 

croupous, _ differential di'agnosis in acute 
bronchitis, 395 

fibrinous, 416 

lobar, 416 

lobular, 414 

pleuro, 416 ^ 

as complication in acute bronchitis, 396 

as complication in hay asthma, 393 

as complication in punctured wounds of 
chest, 131 

as complication in abrasions and contu- 
sions of chest, 128 

as complication in cholera, 506 

as complication in amputation of femur, 

as complication in influenza, 406 

as complication in abscess of liver, 452 

as complication in congestion of lungs, 409 

as complication, incisions and lacerations of 
neck, 120 _ 

as complication in chronic interstitial ne- 
phritis, 468 

as complication in acute parenchymatous 
nephritis, 464 

differential diagnosis in pleuritis, 411 

as complication in acute articular rheuma- 
tism, 519 

as complication in typhoid feVer, 496 

as complication in typhus fever, 499 
Pneumocele, complication in punctured 

wounds of chest, 132 
Pneumonitis, 416 
Pneumothorax, 420 

'complication in abrasions and contusions 
of chest, T28 

differential diagnosis in emphysema, 402 
Poisons, gases, 

carbon^ dioxid, 590 

carbonic acid, 590 

carbonic oxid, 592 

carbon monoxid, 592 

coal, 592 

hydrogen sulphid, 594 

illuminating, 592 

sulphuretted hydrogen, 594 

water, 592 
Poisons, mineral, 

acetate of lead, 542 

antimony, 528 

aqua fortis, 547 

arsenic, 531 

bismuth. 533 

butter of antimony, 528 

carbolic acid, 534 



Poisons-, carbonate of lead, 542 

Ceruse, 542 

copper, 536 

copper arsenite, 531 

creosote, 534 

Goulard's extract, 542 

hydrochloric acid; 538 

hydrocyanic acid, 536 

Kermes, mineral, 528 

lead, 542 

mercury, 544 

nitric acid, 547 

oil of vitriol, 552 

Paris green, 531 

phenol, 534 

phosphorus, 550 

rough-on-rats, 531 

Scheele's green, 531 

sugar of lead, 542 

sulphuric acid, 552 

tartar emetic, 528 

vitriol, 552 

white lead, 542 
Poisons, miscellaneous, 

acetanilid, 574 

alcohol, methyl, 576 

alkalies, caustic, 582 

ammonia, 578 

antipyrin, 574 

cantharides, 579 

caustic, alkalies, 582 

chloral, 584 

Columbian spirit, 576 

hartshorn, 578 

iodine, 586 

concentrated lye, 582 

phenacetin, 574 

ptomaine, 587 

snake, 589 

Spanish flies, 579 

methyl, alcohol, 576 

volatile alkali, 578 
Poisons, vegetable, 

acid, potassivim oxalate, 572 

acid of sugar, 571 

acetic acid, 555 

aconite, 556 

atropine, 558 

1)elladonna, 558 

blue rocket, 556 

cocaine, 559 

colchicum, 561 

deadly night-shade, 558 

essential salt of lemons. 572 

henbane, 558 

hyoscyamus, 558 

ivy, 562 

Jimson weed, 558 

meadow, saffron, 561 

mushroom. 565 

monkshood. 556 

morphine. 560 

nux vomica. 567 

oak. 562 

opium, 560 

oxalic acid, 571 

rhus. 562 

salt of sorrel, 572 

stramonium. 558 

strychnine, 567 

siniiac. 562 

thorn apple. 550 

wolfsbane. 556 
Poisoning, atropine. 558 

arsenical, differential diagnosis in anti- 
motiy. 520 

arsenical, differential diagnosis in morcurj'. 
545 

by concentrated lye, 582 

by creosote. 534 

by fixed alk.ilios. 5v^: 



644 



INDEX 



Poisoning by lead acetate, 542 

by Paris green, 531 

by poisoned dogwood, 562 

by poison ivy, 562 

chronic lead, ditferential diagnosis in oc- 
cupation neurosis, 360 

chronic opium, aifferential diagnosis, co- 
caine, 560 

copper, 536 

differential diagnosis, phosphorus, 551 

differential diagnosis in cholera morbus. 
432 

mushroom, 565 

opium, 569 

differential diagnosis, chloral, 585 

ptomaine, 587 

ptomaine, differential diagnosis in appen- 
dicitis, 430 

rhus, 562 

snake, 589 

strychnine, differential diagnosis in tetanus, 
368 

uremic, 475 
Policy, disabilitj', 56 

forms, knowledge of (accident), 599 

forms, knowledge of (health), 606 

general health, 56 

special health, 56 
Policies, accident, 47 

combination, 57 

health, 56 

special health, 59 

unlimited, 57 
Poliomyelitis, acute anterior, differential 
diagnosis in acute myelitis, 351 

chronic, 344 
Polyneuritis, 358 
Post diphtheritic paralysis, 401 
Posterior spinal sclerosis, 343 
Potassium and antimony tartrate, 52S 

oxalate, acid, 572 
Pott's fracture, complication in dislocation 

of ankle, 302 
Pregnancy, differential diagnosis in ascites, 

503 
Prescribing by examiner, no (accident), 2-/ 

by examiner, no (health), 33 

by examiner, no (liability). 45 
Pressure within the skull, differential diag- 
nosis in facial paralysis, 362 
Process, acromion, fractures of, as complica- 
tion, 225 
Processes, fractures of. complication, dislo- 
cation of elbow joint, 232 
Proctitis, 448 
Professional neurosis, 359 
Prognosis, diagnosis and (accident), 28 

health, 36 

diagnosis and, 6 
Progressive muscular atropb^^ 344 

differential diagnosis in muscular rheuma- 
tism, 521 
Promptness, 13 
Prosopalgia, 352 

Prostate gland, enlargement of, 194 
Prostatitis, acute, 194 

chronic, 194 
Prostration, nervous, 354 
Provisional settlement (accident), 603 
Pruritus, 508 
Prussic acid, 539 

Pseudo-angina, differential diagnosis in an- 
gina pectoris, 2,72. 
Pseudo-tabes, 358 
Ptomaine poisoning, 587 

differential diagnosis in apnendicitis, 430 
Ptosis, complication in abrasions and contu- 
sions of eyelids, 80 
Pubic articulations, sprains of, 282 
Pulmonalis, phthisis, 424 
Pulmonary' consumption, 424 

emphysema, 401 



Pulmonary engorgement, 409 

tuberculosis, 424 

tuberculosis, acute, 419 

tuberculosis, as complication in diabetes 
mellitus, 508 

tuberculosis, as sequelre in catarrhal pneu- 
monia, 416 
Punctured wounds of 

abdomen, 14- 

arm, 203 

back, 161 

bladder, 150 

Chest, 130 

diaphragm, 149 

elbow, 209 

eyelids, 81 

face, 75 

fingers, 217 

foot, 279 

forearm, 209 

gall bladder, 149 

hands, 217 

hip, 264 

leg, 272 

liver, 149 

neck, 121 

scalp, 67 

shoulder, 203 

skull, 97 

spleen, 149 

thigh, 264 

toes, 279 

wrist, 217 
Punctures of the esophagus, complication in 

punctured wounds of chest, 132 
Purging, 436 
Purpose of examination (acQident), 23 

health, 31 

liability, 38 
Putrid fever, 498 

sore-throat, 399 
Pyelitis, 471 

calculous, differential diagnosis. 472 

differential diagnosis in cj^stitis, 470 

suppurative, 471 

as complication in renal calculi, 474 

tuberculous, differential diagnosis, 472 
Pyelonephritis, 471 
Pyelonephritis, complication in fractures and 

dislocations of vertebrae, 170 
Pyemia, as complication in burns and scalds 

of scalp, 69 
Pyothorax, differential diagnosis in pleuritis, 
411 

QUARANTINE indemnity in health policies, 

' 59 
Quinsj', 422 

RABIES, 513 

Radius, fractures of, 247 

Rashes, accidental, dift'erential diagnosis in 

scarlet fpver, 490 
Rectitis, 448 

Rectal, abscess (ischio). 192 
Rectum, catarrh of, 448 

rupture of, complication in fractures of 
pelvis, 306 
Recurrens, febris, 487 
Red granular kidney, 467 

neuralgia, 352 
Reduction of Fehling's solution, differential 

diagnosis in diabetes mellitus, 508 
Relapses, complication in typhoid fever, 496 
Relapsing fever, 487 
Relations of examiner (liability), 39 

with agent, 1 5 
Remarks (accideT:t), 28 

health, z^ 

in reference to accident policies, 55 
Remittent fever. 482 



INDEX 



(yil 



Remittent fever, differential diagnosis in 
gastric catarrh, 440 

differential diagnosis in relapsing fever, 488 

differential diagnosis in yellow fever, 500 

malignant, 484 
Renal calculi, 473 

colic, 473 

colic, differential diagnosis in appendicitis, 

colic, differential diagnosis in cholelithiasis, 

455 
differential diagnosis in gastralgia, 438 
differential diegnosis in intestinal ob- 
struction, 446 
differential diagnosis in peritonitis, 516 
Renal or cardiac asthma, differential diag- 
nosis in asthma, 392 
Reports, impartial, 19 
Requirements, company (accident), 27 

company, (health), 33 
Responsibility, 20 
Retina, atrophy of, complication in diabetes 

mellitus, 508 
Retropharyngeal abscess, differential diag- 
nosis, pharyngitis, 413 
Rheum, salt, 330 
Rheumatic fever, 517 

pharyngitis, differential diagnosis, pharyn- 
gitis, 413 
Rheumatism, acute articular, 517 

of abdominal muscle, differential diagnosis 

in peritonitis, 516 
as complication in angina_ pectoris, _ 373 
gonorrheal, differential diagnosis in acute 

articular rheumatism, 518 
gonorrheal, differential diagnosis in dislo- 
cation of knee joint, 295 
inflammatory, 517 
muscular, 520 

muscular, differential diagnosis in abra- 
sions and contusions of back, 159 
sciatic, 363 

acute articular, differential diagnosis in 
sprains of the acromio-clavicular and 
shoulder joints, 223 
acute articular, differential diagnosis in 

dislocation of the ankle joint, 301 
acute articular, differential diagnosis in 

sprains of ankle joint, 300 
acute articular, differential diagnosis in 

dengue, 479 
acute articular, differential diagnosis in 

in differential diagnosis, sprains of hip 

joint, 284 
acute articular, differential diagnosis in 

dislocations of knee joint, 295 
acute articular, differential diagnosis in 
sprains of knee joint. 291 
Rheumatoid arthritis, differential diagnosis 
in gout, 512 
differential diagnosis m acute articular 

rheumatism, 518 
differential diagnosis, in sprains of hands 
and fingers, 238 
Rhinitis, acute, 397 ^ 

Rhus poisoning, 562 
Ribs, dislocations and fractures of, 142 

dislocations and fractures of. as compli- 
cation in abrasions and contusions of 
chest, 128 
fractures and dislocations of, as complica- 
tion in fractures and dislocations of vcr- 
tebrre, 170 
Right ventricle, dilatation of, 392 
Ring-around, 332 
Rocket, blue, 556 
Rose cold, 393 
fever, 393 

the, 509 ,. . . , 

Rotheln, differential diagnosis in measles, 

486 



Rough-on-rats, 531 
Round ulcer of the stomach, 443 
Rubeola, 486 
Rupture, 151 
bladder, complication in abrasions and 

contusions of abdomen, 144 
intestines, 145 

lungs, complication in abrasions and contu- 
sions of chest, 128 
rectum, as complication in fractures of pel- 
vis, 306 

SACRO-ILIAC articulation, sprains of, 282 

tuberculosis of, differential diagnosis in 
sprains and dislocations of the pubic and 
sacro-iliac articulations, 283 
Saffron, meadow, 561 
Sailors' fever, 500 

Salt of lemon, essential, 572 * 

Salt rheum, 330 

of sorrel, 572 

spirit of, 538 
Scalds, 

abdomen, 134 

arm, 205 

back, 162 

chest, 134 

elbow, 211 

eyelids, 83 

face, 77 

fingers, 220 

foot, 281 

forearm, 211 * 

hand, 220 

hip, 2o6 

leg, 275 

neck, 122 

scalp, 68 

shoulder, 205 

thigh, 266 

toes, 281 

wrist, 220 
Scall, 330 
Scalp, 

abrasions, 61 

abscess of, as complication in contusions of 
scalp, 64 

burns, 68 

contusions, 63 

incisions, 65 

lacerations, 66 

punctured wounds, 67 

scalds, 68 

tumors of, as complication in contusions of 
scalp, 64 
Scapula, fractures of, 241 
Scarlatina, 489 
Scarlet fever, 4S9 

differential diagnosis in acute tonsilttis. 423 

differential diagnosis in dengue. 479 

digerential diagnosis in diphtheria. 400 

differential diagnosis in measles. 4S6 
Scars, sequehv in burns and scalds of hack. 

164 
Schecle's acid. 530 

green. 531 
.Sciatic nerve, neuralgia of, 363 

rheumatism, 263 
Sciatica, 363 
Sclerosis, amyotrophic lateral. 344 

kidney. 467 

liver. 457 

posterior spinal. 343 
Sclerotic coat, ulcers of. S5 

endocarditis. 385 
Secontlary hemorrhage. complication in 

ftaotnre of supcrio'- maxillary. iit 
Self mutilation, differential diagnosis in am- 
putation of toes. 3-^6 
Semi-lunar cartilages, dislocation of. 20S 
Sensitiveness, sequel.e in sun-stroko. ?fi6 



646 



INDEX 



Septic arthritis, differential diagnosis in acute 
articular rheumatism, 518 
osteomyelitis, as complication in contu- 
sions of scalp, 64 
peritonitis, as complication in fractures of 
pelvis, 306 
Septicemia, as complication in amputation of 
the foot, 323 
as complication in carbunculus, 329 
as complication in punctured wounds of 

the leg, 274 
as complication in burns and scalds of 
scalp, 69 
Settlement, provisional (accident), 603 
Sexual organs, male, and surrounding parts, 
abrasions and contusions of, 175 
incisions and lacerations of, 176 
Shingles, 334 
Ship fever, 498 
Shoulder, 

abrasions, 201 
burns, 205 
dislocation, 226 
contusions, 201 
incisions, 202 
joint, dislocation of, 226 
lacerations, 202 * 
punctured wounds, 203 
scalds, 205 
sprains of, 223 
^ick headache, 346 
Sickness, falling, 341 
Side, stitch in the, 410 
Siderans, typhus, 498 
Simple angina, 413 
continued fever, 492 
endocarditis, 373 
gastritis, acute, 439 
glycosuria, differential diagnosis, 507 
keratitis, differential diagnosis, cornea and 

sclera, 86 
neuritis, 356 

differential diagnosis in neuralgia, 3 =52 
Simple or non-suppurating ulcers, differen- 
tial diagnosis in cornea and sclera, 86 
siriasis, 365 
Sinus, thrombosis of the lateral, differential 

diagnosis, abscess of brain, loi 
Simple erythema, differential diagnosis "in 

abrasions of the face, 71 
Skin tabs, 188 
grafting, sequelae in burns and scalds of 
back, 164 
Skull, fractures o£, 94 ... 

pressure within, differential diagnosis m 

facial paralysis, 362 
punctured wounds of, 97 
Sloughing, complication in burns and scalds 

of chest and abdomen, 135 
Smallpox, 522 
black, 524 
confluent, 524 
differential diagnosis in cerebro-spma' 

fever, 478 , 

differential diagnosis m scarlet fever, 490 
hemorrhagic, 524 
malignant, 524 
Snake poisoning, 589 
Softening of the spinal cord, 350 

of the spinal column, sequelse in sprains 
of back, 167 
Solution, reduction of Fehling's, differential 

diagnosis, diabetes mellitus, 508 
Sore-throat, 407 
acute, 413 

malignant ulcerous, 399 
putrid, 399 
Sorrel, salt of, 572 
Spanemia. 371 
Spanish flies, 579 
Spasm of the stomach, 437 



Spasmodic asthma, 390 

asthma, differential diagnosis in emphy- 
sema, 402 
cholera, 504 

laryngitis, differential diagnosis in acute 
catarrhal lar5^ngitis, 408 
Special death indemnity in accident policies, 
51 
health policy, 56-59 
Specialty, a, 11 
Specific urethritis, 186 
Spinal congestion, 346 

column, softening of, sequelae in sprains 

of back, 167 
cord, concussion of, 171 
cord, hemorrhage involving, differential 

diagnosis in acute myelitis, 351 
cord, softening of, 350 
fever, cerebro, 477 
hyperemia, 346 
irritation, 354 
meningitis, 364 
meningitis, acute, differential diagnosis in 

acute myelitis, 351 
muscular atrophy, chronic, 34.'! 
sclerosis, posterior, 343 
Spinalis, leptomeningitis, 364 

plethora, 346 
Spine, concussion of, complication in sprains 

of the back, 167 
Spirillum fever, 487 
Spirit, Columbian or colonial, 576 

of salt, 538 ^^ 

Spleen, punctured v/ounds of, 149 9^1 

Splenica, anemia, 377 'Vifl 

Sporadic cholera, 431 ' "*■ 

Spotted fever, 477-498 

Sprains, acromio-clavicular articulation, 223 
ankle, 299 
back, 165 
of back, differential diagnosis in muscular 

rheumatism, 520 
as complication in abrasions and contu- 
sions of back, 160 
elbow joint, 229 
fingers, 237 
foot, 303 
hands,_ 237 
hip joint, 284 
knee joint, 291 
as a complication in contusions cf knee 

joint, 262 
pubic joint, 282 
sacro-iliac articulations, 282 
shoulder joint, 222, 
toes, 303 
wrist joint, 233 
St. Anthony's fire, 509 
Stenocardia, 272 

Stenosis, complication in acute toxic gas- 
tritis, 442 
Sterno-clavicular articulation, dislocation of, 

136 
Sternum, dislocation of, 140 
fracture of, 140 

fracture of, as complication in abrasions 

and contusions of chest, 128 _ _ j 

fractures and dislocations, as a complication! 

in fractures and dislocations of verte-l 

brae, 170 

Stitch in the side, 410 

Stomach, cancer of, differential diagnosis in 
gastric ulcer, 444 
colic, 437 

dilatation of, differential diagnosis, pneu- 
mothorax, 421 
injuries, 149 
neuralgia of, 437 
perforation of, complication in gastric 

ulcer, 444 
round ulcer of, 443 



INDEX 



647 



Stomach, rupture of, as complication in abra- 
sions and contusions of abdomen, 144 
spasm of, 437 

ulcer of, as complication in hemoptysis, 404 
ulcer of, differential diagnosis in cholelith- 
iasis, 454 
Stone, blue, 536 
Stones, gall, impacted, 452 
Stramonium poisoning, 558 
Strangulated hernia, 445 

as complication in hernia, 155 
Stricture, intestinal, 445 
Stroke, a, 339 
heat, 36s 
sun, 365 

sun, differential diagnosis in apoplexy, 341 
Strychnine poisoning, 567 

poisoning, differential diagnosis in tetanus, 
,368 

Subacetate lead poisoning, 542 
Sub-acute gastritis, 439 
Subcutaneous emphysema, complication in 

punctured wounds of chest, 132 
Subjects, papers on medical, 614 
Sugar, acid of, 571 
Sugar of lead poisoning, 542 
Sulphid, hydrogen, 594 
Sulphuretted hydrogen, 594 
Sulphuric acid poisoning, 552 

differential diagnosis in hydrochloric acid, 
538 
Sumac, poison, 562 
Sun-stroke, 365 

differential diagnosis in apoplexy, 341 
Superior maxillary, fracture of, complication 

in fractures of malar bones, _ no 
Suppurating parotiditis, complication in abra- 
sions and contusions of neck, 117 
Suppuration of inguinal glands, 156 
lung, circumscribed, 389 
parotid gland, complication, 506 
Suppurative appendicitis, _ 429 

appendicitis, as complication in appendici- 
tis, 430 
arthritis, differential diagnosis in sprains 

of elbow joint, 230 
encephalitis, 100 
hepatitis, 451 
nephritis, 471 
pyelitis, complication, 474 
tonsilitis, 422 
Surgical indemnities in health policies, 59 

operations, fees for, in accident policies, 50 
Swamp fever, 480 
Swelling, 159 

differential diagnosis in abrasions and con- 
tusions of back, 159 
parotid glands, complication in typhus 
fever, 499 
Symptoms, cerebral, in typhoid fever, differ- 
ential diagnosis in acute cerebral lepto- 
meningitis, 348 
Syncope, differential diagnosis in apoplexy, 

339 
Synocha, 492 
Synovitis, acute, 

as complication in sprains of acromio-cla- 

vicular and shoulder joints, 224 
as complication in sprains of the elbow 

joint, 230 
as complication in dislocation of the pa- 
tella, 297 
as complication in fractures of the pa- 
tella, 314 . . , , 
tenio, as complication in felon, 333 
Syphilis, as complication iii angina pectoris, 

373 
differential diagnosis in suppuration of the 

inguinal glands, 157 
differential diagnosis in smallpox. 5^4 
Syphilitic dactylitis, differential diagnosis, 

238 



Syphilitic enlargement of the liver, differ- 
ential diagnosis, 456 

enlargement of the testes, differential diag- 
nosis in cancer of penis and testes, 179 

enlargement of the testes, differential diag- 
nosis in epididymitis and orchitis, 181 

ulcers, differential diagnosis in cornea and 
sclera, 86 

ulcers, differential diagnosis in varicose 
ulcers, 337 
Syringomyelia, differential diagnosis in pro- 
gressive muscular atrophy, 345 

TABS, skin, 188 
Tabes dorsalis, 343 
Tact, 12 

Tarsus, fractures of, 321 
Tartar emetic, 528 
Tartrated antimony, 528 
Telegraphists' cramp, 359 

Temporary dislocations as complication in 
sprains of elbow joint, 230 
dislocation in sprains of wrist joint. 234. 
Temporo-maxillary articulation, dislocation 

of, 105 
Tenosynovitis, complication in felon, 333 
Terms, medical, z-j 

Testes, atrophy of one or both, complication 
in incisions and lacerations of male 
sexual organs, 177 
syphilitic enlargement of, differential diag- 
nosis in cancer of the penis and testes, 
179 
syphilitic enlargement of, differential diag- 
nosis in epididymitis and orchitis, 181 
tuberculosis of,_ differential diagnosis in 
cancer of penis or testes, 179 
Testicle, tuberculous disease of, differential 
diagnosis in epididymitis and orchitis, 
182 
Tetanus, z^7 

as complication in punctured wounds of 

back, 162 
cephalic, 367 
as complication in burns and scalds of face, 

79 
as complication in incisions of face, 74 
as complication in punctured wounds of 

face, "jd 
as complication in punctured wounds of 

foot and toes, 280 
as complication in punctured wounds of 

neck, 121 
differential diagnosis in nux vomica and 

strychnine, 568 
as complication in burns and scalds of 

scalp, 69 
as complication in punctured wounds of 

scalp, 6-j 
as complication in punctured wounds of 

shoulder and arm, 204 
as complication in punctured wounds of 

skull. 98 
differential diagnosis in spinal meningitis. 

365 
as complication in incisions and lacerations 

of wrist, hands and fingers. ii6 
as complication in punctured wounds of 
wrists, hands and fingers, 219 
Tetter, 330 
Thermic fever, 365 
Thigh. 

abrasions. 259 
amputations, 3 1 1 
burns. 266 
contusions, 259 
incisions. 262 
lacerations, 262 
punctured wounds, 264 
scalds, 2^(> 
Tiiorn-apple. 55S 
Throat, sore. 407-413 



648 



INDEX 



Thrombosis of the lateral sinus, differential 
diagnosis in abrasions and contusions of 
brain, loi 
Thyroid gland, differential diagnosis in 

abrasions and contusions of neck, ii6 
Tibia, fractures of, 315 
Tic-douloureaux, 352 
Time of examination, 2 

phj'sicians, 5 
Tineo tarsi, differential diagnosis in burns 

and scalds of eyelids, 84 
Toes, 

abrasions, z-jS 
amputation, 325 
burns, 281 
contusions, zyd 
dislocation, 304 

fractures of the phalanges of, 324 
incisions, 277 
lacerations, 2^7 
punctured wounds, 279 
scalds, 281 
sprains, 303 
Tonsilitis, 422 

acute, differential diagnosis in pharyngitis, 

413 
catarrhal, 413 
follicular, 422 

follicular, differential diagnosis in diph- 
theria, 400 
differential diagnosis in scarlet fever, 490 
suppurative, 422 
Torpid liver, 459 
Torticollis. 520 

as complication in abrasions and contusions 
of neck, 116 
Total disability in health policies, 50 

disability, indemnity for, in accident poli- 
cies, 48 
disability, partial indemnity for, in health 
policies, 59 
Toxic gastritis, acute, 441 

gastro-enteritis, acute, differential diagnosis 
in cholera, 506 
Trachea, injuries of, 124 

Trachoma, differential diagnosis in conjuncti- 
vitis, 89 
Transverse myelitis, 350 _ _ _ 

Traumatic hysteria, differential diagnosis m 

concussion of spinal cord, 172 
Treatment, no criticism of (liability), 46 
Tremens, delirium, differential diagnosis in 

acute cerebral leptomeningitis, 348 
Trials, additional fees tu court, 4 
Trifacial neuralgia, z^2. 
Trismus, 367 
Tripper, 186 

Tuberculosis, 424 , , • • ^ 

complication in fracture of ankle joint, 320 
acute, differential diagnosis m catarrhal 

pneumonia, 415 ,. . . 

acute miliary, differential diagnosis m acute 
bronchitis, 395 . ,. . • , 

acute miliary, differential diagnosis m pul- 
monary tuberculosis, 425 _ _ 
acute miliary, differential diagnosis in ty- 
phoid fever, 404 
acute pulmonary, 419 
bladder walls, complication, 470 , 
of elbow joint, differential diagnosis, 230 _ 
in differential diagnosis, sprains of hip 

joint, 284 . . r 1 

differential aiagnosis m sprains of knee 

joint, 293 
lungs, 424 ... i. u 

lungs, acute, complication m acute bron- 
chitis, 396 . , ^ . 
lungs, as complication in hemoptysis, 404 
lungs, as complication in pleuritis, 411 
as complication in measles, 487 
lungs, as sequels in typhoid fever, 49'' 



Tuberculosis, meningitis, differential diag- 
nosis in cerebro-spinal fever, 478 

pulmonary, 424 

pulmonary, sequelae in catarrhal pneu- 
monia, 416 

pulmonary, as complication in diabetes mel- 
litus, 508 

sacro-iliac joint, differential diagnosis in 
sprains and dislocations of the pubic and 
sacro-iliac articulations, 283 

testes, 179 

of testicle, differential diagnosis, 182 
Tuberculous adentitis, differential diagnosis 
in abrasions and contusions of neck, 116 

arthritis, differential diagnosis, dislocation 
of ankle, 302 

disease, as complication in fractures in- 
volving ankle joint, 320 

disease, differential diagnosis in sprains of 
ankle, 299 

disease, complication in abrasions and con- 
tusions of the hip and thigh, 2^9 

disease, differential diagnosis in dislocation 
of knee joint, 295 

disease, dift'erential diagnosis in sprains of 
knee joint, 293 

disease, differential diagnosis in sprains of 
wrist joint, 234 

fistula, differential diagnosis in fistula in 
ano, 185 

peritonitis, acute, differential diagnosis in 
appendicitis, 430 

of the testes, differential diagnosis in 
epididymitis and orcTiitis, 182 

meningitis, differential diagnosis in acute 
cerebral leptomeningitis, 348 

pyelitis, differential diagnosis, 472 
Tubular nephritis, acute, 463 

chronic, 465 
Tubes, Fallopian, diseases of, differential 

diagnosis in appendicitis, 429 
Tumor, _ differential diagnosis in abscess of 
brain, loi 

dift'erential diagnosis in abrasions and con- 
tusions of back, 159 

face, in differential diagnosis in contusions 
of face, 73 

differential diagnosis in abrasions and con- 
tusions of neck, 116 

ovarian, dift'erential diagnosis in ascites, 503 

scalp, as complication in contusions of 
scalp, 64 
Typhilitis, 429 
Typhoid fever, 493 

as complication in appendicitis, 430 

bilious, 487 

cerebral symptoms in, differential diagnosis 
in acute cerebral leptomeningitis, 348 

differential diagnosis in appendicitis, 430 

differential diagnosis in acute gastric ca- 
tarrh, 440 

differential diagnosis in cerebro-spinal 
fever, 477 

dift'erential diagnosis in catarrhal enteritis, 
.435 

differential diagnosis, pernicious malarial 
fever, 485 

differential diagnosis in remittent fever, 483 

differential diagnosis in typhus fever, 498 
Typho-malarial fever, 482 
Typhus abdominalis, 493 

cerebro-spinal, 47-7 

exanthematic, 498 

fever, 498 

fever, differential diagnosis in cerebro- 
spinal fever, 47.7 

differential diagnosis, relapsing fever, 480 

differential diagnosis, smallpox, 524 

icterode, 500 

siderans, 498 

petechial, 498 



1 



INDEX 



649 



ULCER, as complication in abrasions and 
contusions of leg, 269 
and abscesses, as complication in cholera, 

S06 
chronic, 335 
chronic gastric, 443 
cornea and sclerotic coat, 85 
eczematous, 335 
gastric, chronic, 443 
gastric, 443 
gastric, diUerential diagnosis in gastralgia, 

438 
hemorrhagic, 335 
herpetic, differential diagnosis in cornea 

and sclera, 86 
larynx, as complication in acute catarrhal 

laryngitis, 408 
peptic, 443 
perforating, 443 

simple or non-suppurating, differential diag- 
nosis in cornea and sclera, 86 
stomach, round, 443 

stomach, as complication in hemoptysis, 404 
stomach, differential diagnosis in cholelith- 
iasis, 454 
syphilitic, in cornea and sclera, 86 
syphilitic, differential diagnosis in varicose 

ulcer, 337 
varicose, 335 
Ulcerative colitis, 433 

endocarditis, acute, differential diagnosis, 

in typhoid fever, 496 
phthisis, 424 
Ulcerous sore-throat, malignant, 399 
Ulna, fractures of, 247 
Unlimited health policy, 57 
Upper extremity, amputations of, 245 
Uremia, 475 

as complication in chronic interstitial ne- 
phritis, 468 
as complication in acute parenchymatous 

nephritis, 464 
as complication in pyelits 472 
Uremic coma, 475 

differential diagnosis in apoplexy, 340 
differential diagnosis in concussion of 

brain, 103 
convulsions, 475 
intoxication, 475 
poisoning, 475 
Urethra, injury to the male, 195 
Urethral disease, complication in epididymi- 
tis and orchitis, 182 
Urethritis, 197 
specific, 186 
Urinary examinations, 3 

Urine, extravasation of blood and, complica- 
tion in incisions and lacerations of male 
sexual organs, 177 
Uterus, injuries to the. complication in frac- 
tures of pelvis, 306 

VAGINA, injuries to the, complication in 

fractures of pelvis, 306 
Valvular diseases of heart, 385 
Valvulitis, :i7Z 

-Varicella, differential diagnosis in smallpox, 
524 
Varicocele, 198 

dift'erential diagnosis in hernia, 155 
Varicose ulcer, 335 
Variola, 522 
Varioloid, 524 
Vein, inflammation of. 3S3 
Venenata, dermatitis. 562 
Venereal catarrh, 186 _ 

disease, as complication in cystitis. 470 
disease, as complication in suppuration of 
the inguinal glands. 157 



Venereal disease, as complication in injuries 

and diseases of male sexual organs, 176 

Ventricle, right, dilatation of, sequelce in 

asthma, 392 
Vertebrae, fractures of, 168 

differential diagnosis in concussion of 
spinal cord, 174 
complication in abrasions and contusions of 

chest, 128 
fractures, as complication in punctured 

\vounds of back, 162 
caries of, sequelae in sprains of back, 167 
Vertebral column, fractures and dislocations, 
as a complication in spi-ains of the back, 
167 
Vertigo, sequelae in sun-stroke, ^66 
Vesicular emphysema, 401 

Vessels, blood, injury to the, as complication 
in dislocation of elbow joint, 232 
injuries to the, as complication in disloca- 
tion of the shoulder joint, 228 
Violin players' cramp, 359 
\'itriol, blue, 536 

oil of, poisoning, 552 
Volatile alkali, 578 
Vomica, nux, 567 
Vomit, black, 500 

WALLS, abdominal, incisions and lacera- 
tions of, 146 

bladder, tuberculosis of, complication, 470 

bladder, cancer of, complication, 470 
Wasting palsy, 344 
Water, ammonia, 578 

gas, poisoning, 592 
Welcomic, accident insurance physicians, 4 
Weed, Jimson or Jamestown, 558 
Weight, age and height, 16 
White blood, zyj 

cell blood, 277 

kidney, large, 465 

lead poisoning, 542 
Whitlow, 222 
Whooping cough, 427 
Winter fever, 416 
Wolfsbane, 556* 
Wood alcohol, 576 

spirit, 576 
Wounds, 

abdomen, 147 

arm, 20^, 

back, 1 6 r 

bladder, 150 

bladder, complication in punctured wounds 
of abdomen, 1-50 

chest, 130 

diaphragm, 149 

elbow, 209 

eyelids, 8-r 

face, 7S 

fingers, 217 

foot, 279 

forearm, 209 

gall bladder, 149 

hands. 217 

hip, 264 

leg, 272 

liver, 149 

neck, 121 

penetrating, of kidneys, complication in 
punctured wounds of abdomen, 150 

scalp. 67 

shoulder. 20Z 

skull. 97 

spleen. 149 

thigh. 264 

toes. 279 

wrist, 2T7 
Wrist. 

abrasions, 213 

burns. 220 

contusions. 213 



650 



INDEX 



Wrist, dislocations, 235 

incisions, 215 

lacerations, 215 

punctured wounds, 217 

scalds, 220 

sprains, 233 
Writers' cramp, 359 
Writing, medical director, 615 
Wry-neck, 520 

as complication in abrasions and contusions 
of neck, 116 

XIPHOID cartilage, complication in abra- 
sions and contusions of abdomen, 145 

YELLOW atrophy of the liver, acute, differ- 
ential diagnosis in phosphorus, 551 



Yellow atrophy of the liver, acute, differen- 
tial diagnosis in yellow fever, 501 

fever, 500 

fever, differential diagnosis in pernicious 
malarial fever, 485 

fever, differential diagnosis in relapsing 
fever, 488 

fever, differential diagnosis in remittent 
fever, 483 

Jack, soo 

ZONA, 334 

Zoster, herpes, 334 

differential diagnosis in eczema, 330 
differential diagnosis in erysipelas, 510 



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